MENTAL HEALTH EUROPE - SANTE MENTALE EUROPE

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MENTAL HEALTH EUROPE - SANTE MENTALE EUROPE

Project completion report to the Commission

Children, Adolescents and Young People up to 24 years in educational and other relevant settings in the project “Mental Health Promotion and Prevention Strategies for Coping with Anxiety, Depression and Stress Related Disorders in Europe” 1. Introduction: The importance of working with children,

adolescents and young people

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In recent years, mental health issues of children, adolescents and young people – particularly the prevention of mental health problems and the promotion of positive mental health – have been receiving considerable attention throughout European Union Member States. The European Commission published a report On the State of Young People’s Health in the European Union in March 2000. Aimed at policy makers, analysts and researchers in the EU Member States, it outlines the particular health risks among young people in the EU and their health and well being and includes a section on mental health. Mental Health Europe, a non governmental organisation based in Brussels and committed to the promotion of positive mental health and the prevention of mental distress, between 1997 and 2001, carried out two Action Projects financed by the European Commission, in the framework of the EU Community Action Plan for Health Promotion, Information, Education and Training. The report “Mental Health Promotion for Children up to 6 Years” was completed in 1999 and “Mental Health Promotion of Adolescents and Young People” was completed in 2001. Reports of the content and outcome of these projects are published in Directory format and are available upon request1. When discussing the mental health status of children, adolescents and young people, it is important to take into consideration the fact that they do not by any means form a homogeneous group. They can be divided into the following subgroups: young children (1-6 years), children (7-12 years), pre-adolescents and adolescents (13-18 years), and young adults (18-24 years). All these different age groups deserve particular and distinctive attention, one of the main reasons being that childhood and adolescence are crucial stages in life. The incidence of many disorders, for instance depression, is known to increase from childhood to adolescence, and to continue to rise into adulthood2. Mental health promotion of these age groups is therefore essential since the influences in the early stages of the life cycle will have an impact on the rates of disorder in later stages of the child and young person’s life. Depression is one of the most prevalent psychiatric disorders that occurs across the life span, and which affects 340 million people world-wide. Depressive symptoms, particularly in adolescents and young people are seen by adults as being part of the mood swings that can occur with changes in the developmental stages of the life cycle. However, if these symptoms do not go away, and the problems are left untreated, they can have long-lasting negative effects in all aspects of the young people in their adult years. Since the pace of a young person’s life is fast, it is important to prevent problems and intervene before it is too late and before problems become overwhelming and unmanageable. Depression commencing in adolescence, is a highly recurrent condition causing severe psychosocial impairment, and is a major public health problem. Depression in childhood and adolescence is associated with subsequent adjustment problems, underachievement in education and suicidal behaviour3. In addition, depression in 1 Directories are available at Mental Health Europe, 7, boulevard Clovis, B-1000 Brussels. 2 Hackauf, Horst and Winzen, Gerda (1999). On the State of Young People’s Health in the European Union. Munich: German Youth Institute, p.27. 3 idem

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children and adolescents has long been associated with conduct or oppositional disorder, aggression, antisocial behaviour, anxiety, and substance abuse {Rohde, Lewinsohn, et al. 1991 269 /id}. According to the epidemiological data available, the lifetime prevalence of major depression is about 4% in the age group 12-17 and 9% at age 184. Although some studies have found depression to be twice as high in females as in males, it has been shown from a developmental perspective that among children, male depressives are twice as prevalent as females, the reverse of the sex ratio in adolescence. The latest findings suggest an increase in the prevalence of adolescent depression5. Moreover, population surveys show that one third of people that have met criteria for major depression in their lifetime report that the first attack occurred before the age of 21 (Andrews, G. 2001) Child adversities have also been linked with the presence of depression later in life. For example, a recent case-control study in Boston indicated that women who had suffered from any abuse in their childhood or adolescence were 3.4 times more likely to suffer from major depression in adulthood6. Other childhood hardships have also been linked to a later risk for depression during adulthood, such as separation from a parent or family turmoil {Kessler, Davis, et al. 1997 393 /id}7. Children of depressed mothers are 50% at increased risk for depression (Downey et al., 1990)8 and children and adolescents who suffer from depression are at greater risk for recurrence of depression than are adults. 4 Hackauf, Horst and Winzen, Gerda (1999). On the State of Young People’s Health in the European Union, p. 27. Munich: German Youth Institute, p. 27. 5 Hackauf, Horst and Winzen, Gerda (1999). On the State of Young People’s Health in the European Union,. Munich: German Youth Institute, p. 27. 6 Wise, Zierler, et al. 2001 246/id 7 Kessler, 1997 8 Downey & Coyne, 1990

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2. Objectives Within the scope of the current large scale project, Mental Health Europe was responsible for the co-ordination of the sector “children, adolescents and young people up to 24 years in educational and other relevant settings”. National partners were selected from Member States of the European Union and the European Economic Area (EEA) countries and were responsible for the project work in their country. From the outset, the objectives of the sector on children, adolescents and young people in educational and other relevant settings were identical to those of the other sectors of the project. On the one hand, these objectives were to gather relevant information concerning the impact of anxiety, depression and related disorders and the management of these problems with regard to promotion and prevention activities in the different EU Member States and the EEA countries. On the other hand, the project aimed at identifying and evaluating strategies, projects and models of best practice from the participating countries, in order to develop a common strategy for coping with the problems of anxiety, depression and related disorders. Such a strategy shall be evidence-based and for that reason there is recognition of the need to identify existing effective projects and policies that can provide a platform to develop an effective and efficient strategy. 3. Process and Methods: Identification and selection of mental

health promotion projects across Europe In order to identify and recruit national partners for this project, Mental Health Europe contacted its national member organisations, the European Network for Health Promoting Agencies (ENHPA), some of the National Members of the EC Health Promotion Committee and others to ask them to propose prospective partners. As a result, a network of national partners was created in 12 of the EU Member States (Denmark, Ireland and Luxembourg did not participate ) and the EEA-countries Iceland and Norway. Represented in the network were partners from institutes, organisations and centres in the field of mental health with a particular interest in mental health promotion and prevention for children, adolescents and young people. The task of the National Partners in each of their countries was to identify and to evaluate, projects and models of best practice in mental health promotion and the prevention of anxiety, depression and related disorders in the target group ofchildren, adolescents and young people up to 24 years and in various settings. National partners were encouraged to contact research institutes and universities in their country where project development, implementation and evaluation are undertaken. This exercise also had the beneficial aspect of putting the practice field in contact with different research groups in their countries and facilitating future collaboration in project design, evaluation and implementation.

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Three experts were appointed with expertise in mental health promotion and prevention of mental illness, child and adolescent mental health promotion, and child and adolescent psychiatry. All three had also been involved in the previous project undertaken by Mental Health Europe in 2000-2001 "Mental Health Promotion of Adolescents and Young People". Their particular task in the current project was to participate in meetings of the network, to help with the development of the inclusion criteria and subsequently in the selection of best practices for the sector. They assisted also with the preparation of the final report, including the conclusions and recommendations derived from the research in the countries involved. During the first meeting of the national partners, a set of key criteria was agreed that the projects to be collected would have to fulfil. The probability of including a project being included in the final list to be recommended for wider use within Europe was related to its capability to fulfil as many as possible of the following criteria: • The project was evaluated by using some kind of a control or comparison group.

If this was not the case, then before and after evaluations may be acceptable . • It was planned and designed by multi-professional teams, including both

practitioners and researchers, and ideally including end users/sufferers in the design.

• It was delivered by multi-professional teams, and ideally had some involvement by end users and involvement of peers.

• It was applied on a larger scale and with larger numbers of people (i.e. at least local level, rather than just one site).

• It used several inter-related methods and approaches such as . education for professionals as well as treatment interventions and therapies.

• It was in place for some time (at least two years and ideally longer). • It was fully reported in writing with full methodological details so that they could be

judged properly. • It was sustainable, did not require special resources, specially trained personnel,

or a great deal of finance – the project could be built on existing capacity. • It was based on a clear assessment of needs and ideally including the expressed

needs of end users. This list of criteria is not an exhaustive list. Partners were asked to identify projects that aimed to promote mental health and prevent anxiety and depression in children, adolescents and young people. Projects included in the review were defined as: Projects that specifically would target and measure anxiety, depression and

related disorders in children, adolescents and young people Projects that would work on wider mental health themes than just anxiety and

depression, for example whole school health, prevention of bullying, maternal well being, but that would include measures of anxiety and depression in its outcomes;

Projects that would target known risk and resilience factors for mental health in individuals (for example self-esteem, self-confidence, ability to make decisions)

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Projects that would target known risk and resilience factors for larger groups, communities, regions or nations (for example poverty, poor levels of social capital)

To collect and systematise the information gathered from each of the projects, the partners were provided with two questionnaires (see questionnaire I in annex 1, and questionnaire 2 in annex 2). These questionnaires had been drafted before the first partner’s meeting and were adapted and modified for the sector of children, adolescents and young people according to the suggestions of the experts and national partners of the sector. Questionnaire I focused on outlining the broad approaches and the prevalence and burden caused by anxiety disorders and depressive disorders. Questionnaire II aimed at collecting detailed information of the projects and practices in each country. The national partners were given six months to identify, select and describe the projects from their country. The project Executive Committee and the experts evaluated the projects subsequently on the basis of a pre-determined system of evaluation and inclusion criteria as described in the next section. 4. Selected projects implemented across Europe 4.1. Results 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 received from Austria, Italy and Germany were rather scant whereas Sweden, Norway, the Netherlands, Portugal and Iceland provided a number of very good projects. The poor responses would appear to be the result of the absence of any national mental health plan in these countries and in particular to the fact that mental health promotion and prevention strategies are still not deemed a priority for a number of 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, depression and related disorders in children, adolescents and young people, it was considered essential to identify and include as best practices only effective and evidence-based projects. Among the 32 projects collected, a total of 15 projects were identified as well evaluated projects but since six of them had not yet been completed, it was decided to select as best practices the nine projects only 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

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sufficient documented evidence of effectiveness and/or sufficient information on the outcome of the project. Of the 32 projects in total, five were focussed on the target group of children with psychiatric parents, five were about awareness-raising, ten projects were school based interventions, six dealt with anxiety, depression, and suicide, two were community interventions 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 note that eighteen projects targeted anxiety and depression, 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 centres, projects working with juvenile offenders, and self-help groups. Strategies which were used in the school setting and adopted a whole school approach encouraged young people to talk about their feelings, to get on better with peers, to manage anger, 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. 4.2. Selection 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 for children and adolescents in coping with anxiety and depression. Projects in schools aimed mostly to raise awareness, to stimulate discussion and to improve the knowledge about mental illness among students and teachers. It is important that teachers are trained so that they recognise early symptoms of anxiety and depression. At the same time, schools should be linked with community services and school staff should be knowledgeable about the scope of services provided by community agencies. Target groups often included the general population of children, adolescents and young people but also more specifically children of psychiatric parents, foster children, 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.

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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 were 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 relation to mental health prevention or promotion interventions against child abuse, and especially in early school settings have yet to be developed. The following chart gives an overview of the selected best practices. A more detailed description with contact details can be found in the annex. All the other projects that were received are also described in the annex.

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COUNTRY PROJECT DESCRIPTION Netherlands

Coping with Depression Course

Group treatment developed to reduce depressive symptoms and to prevent the onset of depressive disorder.

Netherlands

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 precursor of depressive disorders. This intervention was designed to reduce elevated levels of depressive symptoms and enhance cognitive, social & behavioural competence 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 children’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 messages 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 consideration). The psycho-prophylactic intervention in pregnant women with high levels of anxiety (risk group) is able to bring restricted but significant changes, a lower frequency of dystocias and an increased number of women in the social-support network of the mothers near to the birth.

Portugal

Working with juvenile offenders and adolescents at risk in the community

Probation officers working with adolescents with anti-social behaviour in the community. 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 evaluated in 2002. The important aspect of this project is to have juvenile offenders participate and feel empowered changing their own lives and feeling good about it.

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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, supply 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.

Sweden

Love is the best kick

This is a Video film aiming to increase the self-concept of young people about existential 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 understanding 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 pupil’s knowledge about and attitudes towards mental health difficulties

A project teaching pupils about stress, depression, suicide, eating disorders, bullying, and learning disorders.

United Kingdom

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, though non-significant reductions in symptoms of depression, anxiety, over-activity, conduct problems and attachment disorder in the children.

4.3. 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 equally important to work within an overall ‘settings’ approach to ‘health promotion’, which takes account of environments rather than individuals as both the focus for concern as well as a focus for positive well being, and 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

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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 covers all the countries of Europe, has been one of the most successful globally 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 that have been established. There have been several recent large scale systematic reviews of the research evidence which have concluded unequivocally that controlled trials have shown that the whole school approach is more effective than targeting alone when attempting 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 includes 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, including anxiety and depression are extremely widespread, and if an arbitrary population 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; promoting self-esteem; giving personal support, guidance and counselling; building warm relationships; setting clear rules and boundaries; involving people in the process; encouraging 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 problems 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 assessment 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 to 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.

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4.4. Involving young people in the process One criterion for inclusion of projects was that they involve end users, in this case mainly young people themselves, 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 unreliable to know what is in their own best interests. However, there have been some 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). Also, to include a consideration of these views in developing 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. 5. Recommendations The analysis of all the projects from the sector for children, adolescents and young people to promote mental health and prevent anxiety and depression has led to a number of conclusions and recommendations for the Policy Report. (1) Based on the results from Questionnaire I, it has become clear that many countries 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 focus on children, adolescents and young people and which address their needs. Governments should create strong and supportive infrastructures to promote and protect mental well being, collaborate internationally on enhanced anxiety and depression prevention 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 this the planning, 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 evaluation. Young people need to be not only consulted but have genuine power, influence and decision making over policy and practice. Parents likewise need to be similarly involved. (3) Disadvantaged groups of children and young people have been shown to be at high risk for anxiety and depression. 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.

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(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 well being . (5) Holistic approaches need to be used that focus on the whole context in which young people find themselves both as the seat of understanding the causes of problems and as the site for solutions, in a co-ordinated and planned way. This needs to include 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 essential, 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, those 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. (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. (10) Within the overall community approach, well-supervised, safe play and leisure facilities for children, adolescents and young people should be provided throughout their formative years. (11) Attempts need to be made to address the problems young people have within school wherever possible, with non-stigmatising, non-medicalised, interventions. Multiple and different outcomes such as anxiety, depression, substance abuse, suicide and attempted suicide should be addressed simultaneously. (12) Particular efforts need to be made to support young people and their families through times of transition, as these can be a period of particular anxiety and stress. These include for example the move from home to school, from one school to another, and from school to work or higher education.

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(13) More needs to be done to promote the mental health of carers: those who parent, educate, treat and work with young people in various ways. (14) Particular initiatives are necessary to tackle bullying and violence in schools, home and community. (15) An effort is needed to tackle the under achievement of many children throughout the European Community, without putting children under undue pressure, as under achievement has been linked with anxiety and depression. (16) A special focus is required to tackle the pervasive problem of stigma and discrimination that surround mental health problems. (17) There is a need to encourage more training and more multi-professional networking on mental health issues. (18) Whenever possible new and existing initiatives should use and build on the evidence base from controlled, or pre and post evaluation studies, in order to develop appropriate strategies, approaches and programmes where the evidence base and development work should be based on a substantial and well founded body of theory. Far more priority should be given to evaluation of new and existing projects, with a great deal more resource devoted to it, and the creation of more effective partnerships between practitioners and the research centres which have the expertise in this area.

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RECOMMENDATION EXAMPLES 1. BASED ON THE RESULTS FROM QUESTIONNAIRE I, IT HAS BECOME CLEAR

THAT MANY COUNTRIES IN THE EUROPEAN UNION STILL LACK CLEARLY DEFINED MENTAL HEALTH POLICIES OR SIMPLY DO NOT HAVE A NATIONAL MENTAL HEALTH PLAN. THOSE COUNTRIES WHO 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 FOCUS SPECIFICALLY ON CHILDREN, ADOLESCENTS AND YOUNG PEOPLE AND TO ADDRESS THEIR NEEDS. GOVERNMENTS SHOULD CREATE STRONG AND SUPPORTIVE MENTAL WELL BEING INFRASTRUCTURES, COLLABORATE INTERNATIONALLY ON ENHANCED ANXIETY AND DEPRESSION 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.

Dealing with Moods (Netherlands): This project is not part of a governmental mental health policy but just a private project. It would be very helpful to have a national Depression prevention programme or more generally a mental health promoting policy.

Second Step (Norway): Norway will have a clearly defined mental health plan for

children and young people, which will enter into force in autumn 2003. In Norway’s latest report to the UN regarding Children’s rights, young people were asked about what it was like to grow up in Norway. The report is called “Life under 18” (“Livet under 18”).

Life Skills (Sweden): Sweden is one of the countries that lack a clearly defined

mental health plan. Evaluating suicide prevention projects is a way to endorse the government’s interest in this issue. This is one of the goals of the National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP).

Love is the Best Kick (Sweden): The government in Sweden has decided that it

is important to translate the WHO programme “Preventing Suicide: a resource for teachers and other school staff”. This was done at the National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) in a more extensive form.

The Foster Carers’ Training Project (Scotland): Scotland has recently

produced the Scottish Needs Assessment Process Report on child and adolescent mental health which can be downloaded from the Public Health Institute of Scotland web site from www.phis.org.uk. This found that children's mental health can be influenced at many levels of society and that this influence can be improved by good collaborative working between different agencies e.g. consultation to other professional groups can be an effective and efficient way of child and adolescent psychiatrists influencing children's mental health in a much broader way. The Foster Carers’ Training Project (FCTP) fits in with this work in that it sees foster carers as the agents of therapeutic change for the children they look after, but also recognises that a consultative type of training can help carers achieve this.

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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 IMPLE MENTATION 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 EVALUATION. 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.

Dealing with Moods (Netherlands): The end users are involved in the process,

they tested pilot versions of the project. Second Step (Norway): The basis of this project consists of everyday topics and

situations that are well known to children and young people. The teachers using this intervention have to make changes and adaptations to adapt it to their group of students. The implementation of the project involves the participants and the children, as it is their ideas and solutions that will be tried out in real life situations. The project serves as a frame but the students make the picture inside. The involvement of parents is also an important point, as social skills are learned in situations other than in the classroom, and as parents are important role models for their children.


(Portugal): The intervention with the adolescents included – besides a personal and social promotion programme – a group conversation at every session. Adolescents were required to identify their personal and social needs, and were challenged to propose ways to cope with those needs. Although the methodology had been decided beforehand, the specific topics covered depended very much on the results of these conversations, and adolescents were able to choose topics they wanted to discuss.

Life Skills (Sweden): The project was developed in co-operation with users. Love is the Best Kick (Sweden): Many courses were organised for teachers,

which gave opportunity to discuss how to use the intervention in schools and also how to change it to make it suitable for every special school and their pupils.

The Foster Carers’ Training Project (Scotland): Foster Carers had a key role to

play in the design of the randomised controlled trial, by taking part in a qualitative focus group prior to the start of the main study. Children also had a role in helping to refine the questionnaires used as outcome measures.

3. DISADVANTAGED GROUPS HAVE BEEN SHOWN TO BE AT HIGH RISK FOR

ANXIETY AND DEPRESSION. 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.

Dealing with Moods (Netherlands): Several institutes have pointed out the

relationship between social factors and mental ill health. There is still no national policy aimed at reducing ill health and unfavourable social factors.

Second Step (Norway): This project is targets the whole group of students.

Positive feedback is one important tool for the teachers and parents to use. Empathy is also an important part of the project, and teachers report that it becomes easier for the well functioning students to accept those with problems.

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(Portugal): This project is a good example of addressing disadvantaged groups. Adolescents that came from “elsewhere” (e.g. migrants), adolescents with a chronic disease, adolescents from families of unemployed, arrested criminal or unskilled workers with minimum national wage showed increased risk for depression and anxiety, conduct disorders and addiction. Also, taking into consideration the aspects of poverty, social exclusion and school distance, the majority of adolescents that were juvenile offenders had an African background, which was seen as a matter of lack of opportunities and sense of belonging.

The Foster Carers’ Training Project (Scotland): The project had a special

focus on fostered children – among the most disadvantaged in society.

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 WELL BEING.

Dealing with Moods (Netherlands): It is one of the objectives of this project to

strengthen cognitive and social competence as protective factors. Second Step (Norway): The aim of this project is to focus on the positive choices

one can make. Positive feedback from parents is important. The children need to see that positive behaviour gives them attention, as the attention from adults is one thing that children and young people in Norway rate as very important in their lives.


(Portugal): Some of the adolescents in this project were really good at solving problems and “highly resilient”. Work is being carried out taking these characteristics into consideration while trying to help them accept a more pro-social behaviour and cope with their life problems without alcohol, drugs and violence. One hour weekly was used to meet some of the parents and talk to them. The families are often not traditional and some have been arrested for crime themselves.

Life Skills (Sweden) + Love is the Best Kick (Sweden): This is the basic idea

of the projects together with the holistic approach (5) as it is not focusing on problems and especially not suicidal problems. Within each topic in the project, the pupils formulate their own needs and what they should do to meet these needs.

The Foster Carers’ Training Project (Scotland): The project collects

information from foster carers, teachers and from children themselves in an attempt to get a holistic view of the child.

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RECOMMENDATION EXAMPLES 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 PROBLEMS AND AS SITE FOR SOLUTIONS, IN A CO-ORDINATED AND PLANNED WAY. THIS NEEDS TO INCLUDE 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 ESSENTIAL, 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.

Dealing with Moods (Netherlands): This project is only focussing on students. A

more comprehensive approach could indeed be desirable. Step by Step (Norway): This project uses a holistic approach.. The National

Health Association in Norway works with a holistic approach to mental and physical health. They advise the schools and pre-schools using the “Second Step” project to have a plan for a whole-school implementation. The community perspective is very important.


(Portugal): While working with the adolescents, their families and their probation officers, the people responsible for the project aimed to help families cope with these adolescents, and acted as collaborators , including peers in this pro-social approach, so that adolescents can help each other to cope with life challenges instead of encouraging each other to engage in anti-social behaviour. Pro-social behaviour needs to be encouraged and perceived as a “social gain”. This intervention was explained to schools so that these adolescents would not be excluded (this was only successful in some of the schools). This intervention was also explained in the community, namely to job providers, so that these adolescents can get professional training and a job.

Life Skills (Sweden) + Love is the Best Kick (Sweden): Both projects use a

holistic approach.

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.

Life Skills (Sweden): Working with the Life Skills Programme gives the school

nurse and the school counsellors information on the individual needs of the pupils. It is also a way to let the pupils become more acquainted with the school nurse and the school counsellor and less reluctant to seek help.

The Foster Carers’ Training Project (Scotland): Fostered children are such a

group.

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 THE DIFFERENT CULTURAL AND SOCIAL GROUPS.

Second Step (Norway): This project focuses on children in pre-school (age 1-6)

and schools (grades 1-7). The lessons are made to fit the different age groups. The problems that the young children talk about are simpler and less complex than the problems presented by the older children.

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(Portugal): Depression, anxiety, conduct disorders and addiction tend to increase with age between 11 and 16 years, they tend to be related to different features with gender, with girls more prone to internalise and girls more prone to externalise. Co-morbidity is usually high. In this project, the focus was on boys from 14-16 years.

Love is the Best Kick (Sweden): By being in individual contact with children and

adolescents after seeing the video, it is possible to be more aware of their specific needs, which is a reality for teachers and other school staff with students coming from different countries and different cultural backgrounds.

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.

Second Step (Norway): The question that adults teaching this project have to be

able to discuss with the parents is “why is social and emotional learning important?” Information has been put together for the parents, and pre-schools and schools are informed that a successful implementation also involves parents.

Psychosocial intervention with pregnant anxious women (Portugal): This is

a good example of a project supporting good parenthood. Working with juvenile offenders and adolescents at risk in the community

(Portugal): The target group consists of adolescents with highly non traditional families. A broad preventive parenting programme would be most welcome though.

The Foster Carers’ Training Project (Scotland): Training of foster carers may

be a key way of helping fostered children find the secure base they need to develop mental health in later life.

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RECOMMENDATION EXAMPLES 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


(Portugal): Most of the adolescents in this project come from dysfunctional families (poverty, social exclusion- migrant background, alcohol abuse, violence, criminality, etc.). The way we address this fact with adolescents is capacity building ( resilience, problem solving, priority setting, building positive and realistic expectation towards future....)

The Foster Carers’ Training Project (Scotland): Although this project was not

specifically targeted at children whose parents have mental illness, 52% of mothers of the looked after (fostered) children in the study had mental illness or learning disability, so targeting looked after children is one way of targeting this group.

10. WITHIN THE OVERALL COMMUNITY APPROACH, WELL-SUPERVISED, SAFE

PLAY AND LEISURE FACILITIES FOR CHILDREN, ADOLESCENTS AND YOUNG PEOPLE SHOULD BE PROVIDED THROUGHOUT THEIR FORMATIVE YEARS.


(Portugal): The adolescents targeted by this project usually share the following characteristics: poverty, migration condition, living in “bad areas”, lack of schooling and education, lack of leisure facilities and a lack of dreams while being adolescent.

11. ATTEMPTS HAVE TO BE MADE TO ADDRESS THE PROBLEMS YOUNG

PEOPLE HAVE WITHIN SCHOOL WHEREVER POSSIBLE, WITH NON-STIGMATISING, NON-MEDICALISED INTERVENTIONS. DIFFERENT MULTIPLE OUTCOMES SHOULD BE ADDRESSED SIMULTANEOUSLY (ANXIETY, DEPRESSION, SUBSTANCE ABUSE, SUICIDE.

Dealing with Moods (Norway): The project is non stigmatising and

simultaneously addresses depression. Second Step (Norway): This project helps the children to learn how to solve

problems. It helps the pupil understand the problem by defining it and makes him or her realise that there is always more than one solution.


(Portugal): In Portugal’s nation-wide programme, schools were mostly used as the programme setting. When schools were collaborative, results were much higher and the implementation easier. If a broad school-based action preventing mental health problems was possible, these problems could be prevented instead of having to be dealt with. This could include areas, such as anxiety, depression, conduct problems, addiction, suicide, problems of body image, sexual education.

Life Skills (Sweden) + Love is the Best Kick (Sweden): The Life Skills Project

addresses bullying, the working environment, substance abuse, depression and suicide and one of the aims is to promote a help-seeking behaviour. When interventions are discussed, social and psychological interventions are referred to as well as medical interventions.

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12. PARTICULAR EFFORTS NEED TO BE MADE TO SUPPORT YOUNG PEOPLE

AND THEIR FAMILIES THROUGH TIMES OF TRANSITION, AS THEY CAN BE A PERIOD OF PARTICULAR ANXIETY AND STRESS. THESE INCLUDE THE MOVE FROM HOME TO SCHOOL, FROM ONE SCHOOL TO ANOTHER, AND FROM SCHOOL TO WORK OR HIGHER EDUCATION.

Second Step (Norway): Anger is an important part of people’s lives but what is

important is to know how to deal with anger. In this project, children learn how to recognise their own anger, how to calm down, and try to find positive ways to behave.

13. WE NEED TO DO MORE TO PROMOTE THE MENTAL HEALTH OF CARERS:

THOSE WHO PARENT, EDUCATE, TREAT AND WORK WITH YOUNGER PEOPLE IN VARIOUS WAYS.


(Portugal): Working with adolescents who have mental health problems requires a stable mental health from professionals. This project also tries to define the profile of the professionals who can best cope with this challenge.

14. PARTICULAR INITIATIVES ARE NECESSARY TO TACKLE BULLYING AND

VIOLENCE IN SCHOOLS, HOME AND COMMUNITY.

Second Step (Norway): The main idea of this project is the prevention of

violence. The three parts of the project – empathy, problem-solving and anger management – are three important ways on how to prevent violence and bullying.

Love is the Best Kick (Sweden): In the school legislation in Sweden, you are

supposed to have a special programme for tackling bullying and violence and this subject is also part of the programme connected to the video film. There is a special manual for adolescents to help them to start a discussion about different aspects of what can happen to a young person, e.g. stress factors, eating disorders, crisis, depression, alcohol and drugs, what it is like to be bullied and how to overcome difficulties.

15. IN THE EFFORT TO TACKLE THE UNDER ACHIEVEMENT OF MANY

CHILDREN THROUGHOUT THE EUROPEAN COMMUNITY, WITHOUT PUTTING CHILDREN UNDER UNDUE PRESSURE, AS UNDER ACHIEVEMENT HAS BEEN LINKED WITH ANXIETY AND DEPRESSION.


(Portugal): Under achievement is related to being “far from school culture”, discriminated at school or being without expectations or schooling being able to provide a better future. Under achievement is also related to mental health and is due to both internalising and externalising problems.

16. THERE NEEDS TO BE A PARTICULAR FOCUS ON TACKLING THE

PROBLEMS OF STIGMA AND DISCRIMINATION THAT SURROUNDS MENTAL HEALTH PROBLEMS.

Dealing with Moods (Netherlands): Stigma is prevented by focussing on

strengths and empowerment and not on depression. Life Skills (Sweden): Addressing suicidal problems is a way to tackle the stigma

problem.

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17. THERE IS A NEED TO ENCOURAGE MORE TRAINING AND MORE MULTI-

PROFESSIONAL NETWORKING ON MENTAL HEALTH ISSUES.

Second Step (Norway): The project was evaluated in the US and an evaluation

was started in Norway. Funding is also sought for a project that evaluates the project at a European level.


(Portugal): This project always includes professional training and one-year supervision. A manual is always provided. Professionals are also trained, e.g. in Belgium in 2003.

Life Skills (Sweden): The Life Skills Project is evaluated in a quasi-experimental

study with a voluntary intervention group and reference group, but plans are under way to evaluate it in a randomised study.

Love is the Best Kick (Sweden): The project is evaluated by using four different

groups. Two groups were shown the video and the other not. Both groups were then divided into two sub-groups: those who tried to commit suicide and those who did not. The suicidal tendencies had decreased in the group that had watched the video.

18. WHENEVER POSSIBLE NEW AND EXISTING INITIATIVES SHOULD USE AND

BUILD ON THE EVIDENCE BASE FROM CONTROLLED, OR PRE AND POST EVALUATION STUDIES, IN ORDER TO DEVELOP APPROPRIATE STRATEGIES, APPROACHES AND PROGRAMMES WHERE THE EVIDENCE BASE AND THE DEVELOPMENT WORK SHOULD BE BASED ON A SUBSTANTIAL AND WELL FOUNDED BODY OF THEORY. FAR MORE PRIORITY SHOULD BE GIVEN TO EVALUATION OF NEW AND EXISTING PROJECTS, WITH AGREAT DEAL MORE RESOURCE DEVOTED TO IT, AND THE CREATION OF MORE EFFECTIVE PARTNERSHIPS BETWEEN PRACTITIONERS AND THE RESEARCH CENTRES WHICH HAVE THE EXPERTISE IN THIS AREA.


(Portugal): This project was evaluated using a randomised controlled trial and the evaluation was one of the issues that the professionals were overloaded with. But projects have to be evaluated, otherwise they can even be harmful.

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LITERATURE REFERENCES Andrews, G. 2001. “Should depression be managed as a chronic disease?” BMJ, 322, 419-421

Catalano, R.F., Berglund, L., Ryan, A.M., Lonczak, H.S. and Hawkins, J. (2002) Positive Youth Development in the United States: Research Finding on Evaluations of Positive Youth Development Programmes. Prevention and Treatment, (5), article 15. Clarke, G.-N., Hornbrook, M., Lynch, F., Polen, M., Gale, J., Beardslee, W., O'-Connor, E., & Seeley, J. 2001 "A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents", Archives-of-General-Psychiatry, Vol. 58, no. 12, pp. 1127-1134.

Clarke, G., Hawkins, W., Murphy, M., Sheeber, L., Lewinsohn, P., & Seeley, J. 1995, "Targeted Prevention of Unipolar Depressive Disorder in an At-Risk Sample of High School Adolescents: A Randomized Trial of a Group Cognitive Intervention", Journal of American Academy of Child and Adolescent Psychiatry, vol. 34, no. 3, pp. 312-321.

Cohen, J. (1993) Handbook of School-Based Interventions: Resolving Student Problems and Promoting Healthy Educational Environments. San Francisco: Jossey-Bass. Dadds, M. R., Holland, D. E., Laurens, K. R., Mullins, M., Barrett, P. M., & Spence, S. H. 1999, "Early intervention and prevention of anxiety disorders in children: Results at 2-year follow-up", Journal of Consulting and Clinical Psychology, Vol. 67, no. 1, pp. 145-150.

Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M., & Laurens, K. R. 1997, "Prevention and early intervention for anxiety disorders: A controlled trial", Journal of Consulting and Clinical Psychology, Vol. 65, no. 4, pp. 627-635.

Downey G., Coyne, J.C. 1990, “Children of depressed parents: an integrative review”, Psychological Bulletin, 108: 50-76.

Felner, R. D., Brand, S., Adan, A. M., Mulhall, P. F., 1993, "Restructuring the ecology of the school as an approach to prevention during school transitions: Longitudinal follow-ups and extensions of the School Transitional Environment Project (STEP)", Prevention in Human Services, Vol 10, no. 2, pp. 103-136.

Gillham, J., Reivich, K., Jaycox, L., & Seligman, M. 1995, "Prevention of Depressive Symptoms in School Children: Two Year Follow-Up", Psychological Science, Vol. 6, no. 6, pp. 343-351.

Gillham, J. E., Shatte, A. J., & Freres, D. R. 2000, "Preventing depression: A review of cognitive-behavioral and family interventions", Applied and Preventive Psychology, Vol. 9, no. 2, pp. 63-88.

Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman, M. E. P. 1994, "Prevention of depressive symptoms in school children", Behaviour Research and Therapy, vol. Vol 32, no. 8, pp. 801-816.

Kessler, R., Davis, C. G., & Kendler, K. 1997, "Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey", Psychological Medicine, Vol. 27, no. 5, pp. 1101-1119.

Lister-Sharp D., Chapman S., Stewart-Brown SL., Sowden A. (2000) Health Promoting Schools and Health Promotion in Schools: Two Systematic Reviews. Health Technology Assessment, 3 (22). McMillan, J. (1992) A Qualitative Study of Resilient At-Risk Students: Review of Literature. Virginia: Metropolitan Educational Research Consortium. Mrazek, P. J. & Haggerty, R. J. 1994, "Reducing risks for mental disorders: Frontiers for preventive intervention research".Washington: National Academy Press.

Munoz, R. F., Ying, Y. W., Perez-Stable, E. J., & Miranda, J. 1993, "The prevention of depression: Research and practice". Baltimore: John Hopkins University Press.

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Rohde, P., Lewinsohn, P.-M., & Seeley, J.-R. 1991, "Comorbidity of unipolar depression: II. Comorbidity with other mental disorders in adolescents and adults", Journal-of-Abnormal-Psychology, Vol. 100, no. 2, pp. 214-222.

Rutter, M., Hagel, A. and Giller, H. (1998) ‘Anti-social Behaviour and Young People.’ Cambridge: Cambridge University Press. Stewart-Brown, S. (2000) ‘Parenting, well being, health and disease’. In A.Buchanan and B.Hudson (eds) Promoting Children’s Emotional Well-being. Oxford: Oxford University Press, 28-47.

Weare, K. (2000) Promoting Mental, Emotional and Social Health: A Whole School Approach. Routledge.

Wells, J., Barlow, J. and Stewart-Brown, S. (2001) A Systematic Review of Universal Approaches to Mental Health Promotion in Schools. Health Services Research Unit, University of Oxford Institute of Health Sciences. Wise, L., Zierler, S., Krieger, N., & Harlow, B. 2001, "Adult onset of major depressive disorder in relation to early life violent victimisation: a case-control study", The Lancet, Vol. 358, pp. 881-887.

World Health Organization, Department of Mental Health (2002) “Preventing Suicide: A Resource for Teachers and Other School Staff”.

World Health Organization, Department of Mental Health (2002) “ Preventing Suicide: a resource for general physicians“.

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ANNEX 1: PROJECT REFERENCE GROUP SECTOR : CHILDREN, ADOLESCENTS AND YOUNG PEOPLE TO 24 YEARS IN EDUCATIONAL AND OTHER RELEVANT SETTINGS Responsible for the policy co-ordination of the Project and this sector John Henderson Mental Health Europe Boulevard Clovis, 7 B-1000 Brussels Tel:+32-2-2800468 Fax:+32-2-2801604 E-mail: [email protected]

Project Leader

Pascale Van den HeedeMental Health EuropeBoulevard Clovis, 7B-1000 BrusselsTel:+32-2-2800468Fax:+32-2-2801604E-mail: [email protected]

Project Co-ordinator Kirsten Zenzinger Mental Health Europe Boulevard Clovis, 7 B-1000 Brussels Tel:+32-2-2800468 Fax:+32-2-2801604 E-mail: [email protected]

Office Manager Mary Van Dievel Mental Health EuropeBoulevard Clovis, 7B-1000 BrusselsTel:+32-2-2800468Fax:+32-2-2801604 E-mail: [email protected]

NATIONAL PARTNERS: AUSTRIA Pro mente Austria Contact person: Brigitte Hackenberg Figulystr.32 A-4020 Linz E-mail: [email protected]

BELGIUMVlaamse Vereniging voor Geestelijke GezondheidContact person: Paul Arteel Tenderstraat 14B-9000 GentTel: +32-9-22144-34Fax: +32-9-2217725E-mail: [email protected]

FINLAND The Finnish Association for Mental HealthContact person: Kristina Salonen Maistraatinportti 4A FIN-00240 Helsinki Tel: +358-9-615 516 Fax: +358-9-615 51 770E-mail: [email protected]

FRANCE World Psychiatric Association WPA Section on Suicidology Contact person: Jean-Pierre Soubrier WHO Advisor 25, rue de la Faisanderie 75116 PARIS

Tel:: + 33 1 47 04 69 69 Fax: + 33 1 47 04 99 33 email : [email protected]

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GERMANY Institut für Psychologie Universität Lüneburg Contact person: Peter Paulus Scharnhorststr. 1 D-21335 Lüneburg Tel: +49-4131-781702 E-mail: [email protected]

GREECE Association for the Psychosocial Health of Children and Adolescents Contact persons: Makis Kolaitis/John Tsiantis Agiou Ioannou Theologou 19 GR-15561 Athens Fax: +30-1-652 2396 E-mail: [email protected]

ICELAND Gedraekt, the Icelandic MH Promotion Project Contact persons: Hedinn Unnsteinsson/ Dora Gudmunsdottir Tungata 7 IS-101 Reykjavik Tel: +354-570 1700 Fax: +354-570 1701 E-mail: [email protected], [email protected]

ITALY FONDAZIONE IDEA – Istituto per la Ricerca e la Prevenzione della Depressione e dell’Ansia Contact person: Prof. Paolo Lucio Morselli MD Via Statuto 8 20121 MILANO, Italy Tel: +39 02 65 39 94 Fax: +39 02 65 47 16 E-mail : [email protected]

THE NETHERLANDS Trimbos-instituut Contact person: Rianne Van der Zanden Postbus 725 NL-3500 AS Utrecht Tel: +30-297 11 45 Fax: +30-297 11 11 E-mail: [email protected]

NORWAY Voksne for Barn/Adults for Children Contact person: Jan Steneby Arbinsgate 1 N-0253 Oslo 2 Tel: +47 22 12 83 30 Fax: +47 22 44 05 69 E-mail: [email protected]

PORTUGAL PUERI Contact person: Isabel Brito Av. Defensores de Chaves, n°3-6 Esq. P-1000-109 Lisboa Tel: +351 21 7122040 Fax: +351 21 712 0582 E-mail: [email protected]

SPAIN AEN (Asociacion Española de Neuropsiquiatria) Contact person: Consuelo Escudero C/Villanueva 11 E-28001 Madrid Tel: +914314911 Fax: +914314911 E-mail: [email protected]

1.1.1

1.1.2 SWEDEN The Swedish National Organisation for Mental Health Contact person: Mimmi Wänseth Saltmatargatan 5, Box 3445 S-10369 Stockholm Tel: +46 8 347065 Fax: +46 8 328875 E-mail : [email protected]

UNITED KINGDOM Penumbra Contact person: Patrick Little 57, Albion Road UK-Edinburgh EH7 5QY Tel: +44-131 475 2571 Fax: +44-131 475 2391 E-mail:[email protected]

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Experts Prof Philip J. GRAHAM Academic Child Psychiatrist 27, St Albans Road UK-London, NW5 1RG E-mail: [email protected]

Dr Eva JANÉ-LLOPIS Research Group on Prevention and Psycho- Pathology Department of Clinical Psychology & PersonalityUniversity of Nijmegen P.O. Box 9104 NL-6500 HE Nijmegen Email: [email protected]

Dr Katherine WEARE The Health Education Unit Research and Graduate School of Education University of Southampton UK-Southampton SO17 1BJ Email: [email protected]

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ANNEX 2: SUMMARY OF BEST PRATICES

Netherlands

Coping with Depression Course 1. Brief description of the project Originally, the “Coping with Depression Course” is a group treatment for depression. It takes place in a community mental health centre and consists of 12 sessions. 2. Aims of the project The aims of the project are to reduce depressive symptoms, to enhance constructive thinking, to develop relaxation as well as social skills and to engage in pleasant activities. 3. Method of Intervention The 12 sessions mentioned above focus on the following topics: information on depression and the cognitive behavioural view on depression, relaxation skill training, planning of pleasant activities, constructive thinking, social skills and assertiveness, consolidation and relapse prevention. 4. Duration of the project The project’s duration is 12 sessions, once a week or every fortnight, every session lasts two hours. There is a possibility to add one or two booster sessions. 5. Target group/Participants Subclinically depressed adults (18-65 years) but versions of the “Coping with Depression Course” for preventive use also exist for adolescents and for the elderly (55+)

6. Co-operation/Participants’ involvement The target group was not involved in the design or the implementation of the project. 7. Outcomes of the project A randomised controlled trial was carried out, in which the intervention group was assigned to the course, and the control group was assigned to a business as usual condition (i.e. no active ingredients were offered by the researchers). Short term results indicate that the course was successful in reducing depressive symptoms as compared to the control group. Follow-up results (up to one year postintervention) show lasting effects of the course in reduction of symptoms. However, upon closer examination, these effects appear to be exclusively restricted to the participants with initially low depression scores. The course had no effect on the prevention of depressive episodes: a quarter of both the course and the control group developed a depressive disorder during the follow-up year. Short term results will be published in Behavior Therapy. Follow-up results are currently submitted for publication. Contact: University of Nijmegen Esther Allart Section Clinical Psychology Postbus 9104 6500 HE Nijmegen Netherlands

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Tel: +24 36 11293 Fax: +24 36 15994 e-mail: [email protected]

Netherlands

Dealing with Moods 1. Brief description of the project “Dealing with moods” is a preventive intervention aimed at young people with a higher risk for symptoms of depression. The intervention is intended to be carried out in schools. The course consists of information and exercises to improve the cognitive, social and problem-solving skills. There are seen as an instrument for prevention of repeated depressive moods and /or the occurrence of depressive disorders. 2. Objectives of the project Short-term: Reduction of depressive symptoms, cognitive and social problems. Development of coping strategies. Long-term: Prevention of depressive disorders and suicides 3. Method of Intervention The project takes place in schools. The training consists of 8 sessions, an introductory meeting and one evaluation meeting after about 1 month. Sessions take 1,25 hours during schooltime. Students have a manual in which they can make homework and do exercises and in which they can read about subjects. Subjects include learning about thinking and the relation between thinking, doing and feeling,, learning how to solve social problems, learning how to raise your activity level and enjoy yourself, and learning about social support. Usually, two trainers train a group of 8-12 students. 4. Duration of the project The project consists of 8 x 1,5 hours. It is now implemented in a secondary school in Maastricht, where it is offered on a yearly basis to students of the third wear (14-16 years old). The development of the intervention took place in 1990-1992 in Nijmegen, in a co-operation between a mental health service providing organisation and the University of Nijmegen (Prof. dr. Hosman). 5. Target group/Participants Adolescents aged between 14 and 18.

6. Co-operation/Participants’ involvement The end users were involved in the project design, two test series were carried out by the (potential) users of the intervention. Some modifications in the final version were made after these sessions. They were also involved in the project evaluation and were given the possibility to give their opinion about the use of the project. 7. Outcomes of the project The project was submitted to a quasi-experimental non-controlled study, a process- and planning evaluation. In total, 99 students took part. It appeared that students participating in the intervention, as opposed tot students who did not (comparison group) improved their level of depressive symptoms, not immediately after the intervention but after 6 months, and they maintained lower levels after one year. Students who participated improved considerably in cognitive skills and to a lesser degree in social skills. No effects were found for problem-solving skills. Contact: RIAGG Maastricht Dr. Marijke Ruiter Parallelweg 45-47 6221 BD Maastricht

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Netherlands Tel: +43 3299 660 Fax: +43 3299 674 e-mail: [email protected]

Norway

Second Step 1. Brief description of the project “Second step” is originally an American programme initiated by the Committee for Children. The second step curriculum is a universal prevention programme designed to reduce aggression and promote social competence. It has been translated and culturally adapted for the Norwegian school and society. It is a practical tool to use for teachers to create a better learning environment in the classroom. 2. Aims of the project The aim of this project is to develop skills that are central to children’s healthy social and emotional development: a) empathy, b) impulse control and problem solving, and c) anger management. 3. Method of Intervention Each Second Step-lesson is based on a photo and a story that demonstrates an important peer relation’s skill. The programme begins with a focus on empathy. It also has a strong focus on labelling one’s own emotions and defining the emotions and feelings of others. The Impulse Control and Problem Solving unit builds upon empathy skills. The sequence of problem-solving skills is based on what we know about effective patterns of thinking in social situations. In guided discussions and role plays, children identify problems, brainstorm, evaluate and implement solutions, assess whether or not they have been effective and try alternate positive strategies if necessary. Finally, in the emotion/anger management unit, calming down strategies are introduced. It is essential for this programme that the staff is properly trained and that parents are informed and included. 4. Duration of the project The programme is meant for use in the classroom or in a group of children in pre-school/Kindergarten. Lessons are recommended to be held regularly, for example one a week. 5. Target group/Participants The programme is mainly targeted at children but two other important target groups are the teachers and the parents as adults need to be a good role model for children.

6. Co-operation/Participants’ involvement The schools using Steg for steg are informed twice a year about the programme and are encouraged to ask questions concerned using the programme or to share ideas. In the newsletter there are articles on use in different schools, training sessions, etc. There are also training sessions for trainers and follow-up sessions once a year. Another important co-operation partner for NHHA are organisations in other countries working with Steg for steg/Second Step. Besides USA, the programme is used in for example Canada, Denmark, Germany, Lithuania and Greenland. 7. Outcomes of the project The project underwent a randomised-control trial in the United States and in Norway, a pre- and post-test at the trial school and a post-test at the control school. The means of measurement in this study in Norway consist of a teacher and pupil evaluation, pupil observation and a pupil sociogramme. The main findings were an improvement in social skills, significant differences in terms of self-evaluation, and fewer interruptions in other people’s conversations. The study also reveals that girls score better than boys in terms of social skills, problem behaviour and in the level reached in school subjects. Regarding problem behaviour, the boys made more progress than the girls. It is also interesting to note that in 2002 the project has been adapted to Kindergarten-level.

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Contact: Norwegian Health Association (NHHA) Kristine Skaar PB 7139 Majorstua NO-0307 Oslo Tel: +47 23 120049 Fax: +47 23 120003 e-mail: [email protected] web sites: www.nasjonalforeningen.no and www.cfchildren.org

Portugal Psychoprophylaxis and Pregnancy.

A Psychosocial intervention among pregnant women with a high level of anxiety

1. Brief description of the project “A Psychosocial intervention among pregnant women with a high level of anxiety” is a clinical research programme implemented in local primary care units (general practitioners units). The target group consisted of women with a low obstetrical risk (in Portugal, only low obstetrical risk pregnant women are in the local primary care units) but with a potential psychological risk (high level of anxiety). 2. Aims of the project The main purpose of this programme was to evaluate the effects or efficacy of a psychosocial intervention among pregnant women with a high level of anxiety. A secondary purpose was the definition of a high risk profile for high anxiety in pregnancy and the observation and analysis of the postnatal evolution of the pregnant women with a high level of anxiety compared to a control group of pregnant women with moderate anxiety. 3. Method of Intervention The psychosocial intervention was assessed by means of a randomised clinical trial. The intervention was provided by one psychiatrist in the intervention group while pregnant women in the control group received routine medical prenatal care only. The psychosocial intervention was defined as a brief therapy with a limited number of therapeutic sessions (4-6) in the third trimester of pregnancy. We tried to involve their husbands/partners in the therapeutic sessions whenever possible. The aims of the therapeutic intervention were: 1) to help mothers to seek support from their potential social support network. 2) to improve women’s emotional state near birth and in the postnatal period. 3) to prevent birth complications. 4. Duration of the project The programme was conducted over a period of 2 and ½ years. 5. Target group/Participants 250 two pregnant women were included in the study. Thirty nine pregnant women aged 18 to 35 years with a high level of anxiety (STAI – Spielberger) were split into two randomised groups, one group that underwent a therapeutic intervention and a control group without intervention. A 3rd group of 40 pregnant women with a moderate level of state and trait anxiety (STAI) was selected with control of parity, age, marital and socio-economic status. 79 women were therefore followed prospectively from the 24th week of pregnancy to the 9th month postpartum.

6. Co-operation/Participants’ involvement 265 consecutive pregnant women attended two local primary care units during the study period. Thirteen women were excluded for several reasons – low level education (10), advanced pregnancy (2) and refusal to participate (1). 46 pregnant women aged 18-35 years with high anxiety levels were involved in the study of the psychoprophilatic intervention . When we compared the forty six women group with the thirty nine women group that remained in the study there were no differences between the two groups. We think that drop-out happened at that time, because we were not enough attentive to the importance of

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having the psychological evaluation and the psychological intervention at the same time (the same date) as the routine obstetrical prenatal consultation. 7. Outcomes of the project The project was submitted to a pre-post evaluation with a control group and a randomised control trial. Contact: Instituto de Ciências Biomédicas de Abel Salazar – Porto University Prof. Dr.ª Paula Pinto de Freitas Departamento de Ciências do Comportamento ICBAS – Universidade do Porto Largo Prof. Abel Salazar, 2 P-4050 Porto Tel: +351-22 2050291, fax: +531-22 2008628 e-mail: [email protected]

Portugal


1. Brief description of the project This programme is a Portugal-wide intervention. It includes areas such as interpersonal communication, problem solving, conflict management, social skills and assertiveness. It is the first structured programme enabling probation officers to work with adolescents with an anti-social behaviour in the community. 2. Aims of the project The aim of this project is to adapt, implement and evaluate a Personal and Social Competencies Programme among juvenile offenders within the structure of a community-based programme. In a second stage, the aim is to train professionals and to supervise their implementation of the programme at national level. The overall objective is to promote the mental health of these adolescents, to increase their coping skills and to prevent personal and social maladjustment in the future. 3. Method of Intervention The programme uses dynamic methodologies, such as role plays, games, group discussions and has already been extensively described and evaluated. The project advocates three key concepts: promoting competencies, participation, and access to facilitating structures in the community. The first year, a pilot study was carried out with 13 juvenile offenders. Their input was very important in terms of alternatives to the programme. The second year, probation officers from all over Portugal were trained. And finally the third year, the process was supervised and evaluated. 4. Duration of the project The programme lasted one year, there were 23 sessions, once a week for 90 minutes each. 5. Target group/Participants 90 adolescents aged between 12 and 16 participated in the programme. 40 attended 60% of the 23 sessions. Only those were included in the final evaluation.

6. Co-operation/Participants’ involvement The adolescents were involved in the evaluation. 7. Outcomes of the project The project was submitted to a pre-post evaluation with a control group. It showed that adolescents increased their ability to solve social problems, showed less deviant behaviour, exhibited less physical and verbal aggression and carried guns less often.

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The strongest feature of the project is the opportunity that juvenile offenders are helped to cope with an alternative pro-social lifestyle in the community, avoiding their placement in a Special Rehabilitation Institution. Another strong feature is the increased competence of probation officers and the multiplicative effect of the training. Contact: Faculdade de Motricidade Humana Estrada da Costa Cruz Quebrada 1499 Lisboa Codex Tel: +351 21 4149152 Fax: +351 21 4151248 e-mail: [email protected] web site: http://www.fmh.utl.pt

Sweden

Life Skills 1. Brief description of the project The programme "Life skills" was developed by a school nurse and a school counsellor in Sweden. The target group is students aged between 13 and 18. The pupils are given the possibility during school time to talk about emotions and to identify psychological problems. Pupils with different backgrounds and who differ emotionally and intellectually teach each other how to find new goals and new solutions. 2. Aims of the project The aim of the project is to create a time-effective method at school to prevent mental and psychosocial ill-health, loneliness and bullying, to give hope that personal problems can be solved, and to supply help and information on how to seek help in an early stage. Another objective is to increase the co-operation between the school healthcare and the teachers, and to increase the ability to identify and help students, and therefore prevent suicidal behaviour. 3. Method of Intervention "Life Skills" consists of one medical and one social part. The medical part is about the effect of the interplay between physical, mental and psychosomatic factors on health and ill-health and deals with questions about health, emotions, stress, crisis, depression and suicidal thoughts. The social part is about the importance of the effect of one’s relationships on health and deals with questions about family, coping with conflicts, school environment, bullying, and the development of an identity and support within the group. 4. Duration of the project The school staff were informed for half a day about the project, depression and suicidal behaviour in youth. Voluntary teachers then took part in a two-day teaching session to learn about the method. Every school creates its own schedule and decides about the scope when using the method. The developers of the programme recommended at least 16 hours per class, divided into four days over a period of several weeks. 5. Target group/Participants The target group consisted of students in secondary school aged between 13 and 18. The evaluations were carried out with pupils that are between 14-15 and 16-17. 6. Co-operation/Participants' involvement The students of the two persons who developed the programme were involved in the design of the programme and also in the implementation. They tried different methods to find the one most suited for all students. 7. Outcomes of the project

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The results of the pilot-study showed positive results in the intervention group compared with a reference group when attitudes and self-reported suicide attempts were assessed by questionnaires before and 2.5 months after the programme. The evaluation comprises 1.000 pupils in the intervention group and 1.000 pupils in the reference group. Preliminary results by means of questionnaires before and one year after the programme indicate that the past year prevalence of self-reported suicide attempts decreased in the intervention group but not in the reference group. Contact: Brittmari Ahlner Eva Hildingsdotter Bengtsson NASP Piper väg 103 Långkärrsv. 17 Karolinska Institutet S-170 03 Solna S-187 44 Täby Box 230 Tel: +46 8 640 89 34 Tel: +46 8 758 72 02 S-0171 77 Stockholm e-mail: [email protected], [email protected] web site: http://www.sll.se/suicid

Sweden

Love is the best kick 1. Brief description of the project As part of the national work involved in suicide prevention, the National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) initiated the producing of a video film about young people’s crises and life situations. By showing it to parents, teachers and other school staff, the knowledge about students in crisis increases and gives the surrounding people increased preparedness to help the pupils in need. 2. Aims of the project The aim of the programme is to increase the self-conception of young people about existential problems, identity, relationships, love and belonging. It also aims at increasing the support among friends and the co-operation between the home, school and other local units. The long-term goal is to provide information about the source of suicidal problems and to find a solution, and thus to prevent suicide. 3. Method of Intervention The method of this programme included the showing of the film, discussions about existential questions and team work. The way the film is designed stimulates discussion between pupils but also increases the contact and the exchange of experiences and feelings between young people and adults. 4. Duration of the project The programme was carried out in several phases, the whole study (including the writing of reports) took four years to complete. First, the film was shown to pupils, youth in a psychiatric ward, teachers, educators, etc. to get comments on the design and content. The film was then shown to pupils and they were then asked to fill in a questionnaire concerning suicide and whether they wanted to participate in the study. Data was then collected from interviews and psychological tools of those who had decided to participate. A year later, the same data was collected from the same pupils. 5. Target group/Participants Pupils aged 16-17 years of age from five different schools in Stockholm.

6. Co-operation/Participants’ involvement Pupils were involved in the beginning when they were asked for comments on the film’s design and content. They were also involved in the evaluation and took part in interviews. 7. Outcomes of the project The results of this programme were collected with two intervention and two control groups.

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The students in general thought that the film gave a lot of opportunities to talk. Generally speaking, most students, regardless of whether they had had suicidal thoughts or not, could identify themselves with some of the characters in the film and it helped them understand their own situation better. Several students also mentioned that they could understand their friends better after the movie. Contact: NASP, National Centre for Suicide Research and Prevention of Mental Ill-Health Box 230 S-0171 77 Stockholm Tel: +46 8 728 70 26 Fax: +46 8 30 64 39 e-mail: [email protected], [email protected] web site: http://www.sll.se/suicid

United Kingdom

The development of adolescent pupils’ knowledge about and attitudes towards mental health difficulties

1. Brief description of the project This project was part of the 5-year Anti-stigma Campaign “Every Family in the Land”, organised by the Royal College of Psychiatrists, to address the problem of prejudice against those with a mental health difficulty. The project was part of the campaign devoted to children and young people. It is a programme consisting of a six lesson module of a mental health teaching programme carried out in schools about changing attitudes towards mental health difficulties in young people. 2. Aims of the project The aims of this projects are to increase knowledge about mental health, to achieve changes on the Strengths and Difficulties score as well as to reduce stigma and prejudice. 3. Method of Intervention The intervention method used was the teaching of well-designed lessons during PSHE lessons (Personal Social and Health Education). The lessons of different sessions on stress, depression, suicide, eating disorders, bullying and learning disorders. 4. Duration of the project The lessons consisted of 6 x 50-minute sessions. 5. Target group/Participants Pupils aged 14-15 years of age in 2 secondary schools in South London.

6. Co-operation/Participants’ involvement The pupils were not involved in the programme design or in its implementation. 7. Outcomes of the project 149 students in the experimental classes and 207 children in the control classes not receiving these lessons were selected for detailed before and after knowledge of mental health problems, the post-test evaluation being given 6 months after the final lesson. It was found that students who received it valued the module. Those who scored highly on the pro-social behaviour sub-scale of the Strengths and Difficulties Questionnaire were particularly likely to value the lessons on bullying, depression and learning problems. Children whose scores suggested that they had conduct problems or were hyperactive were less likely to regard as important the

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lessons on bullying, stress and depression. Students in the experimental classes used significantly fewer pejorative word post-test to describe mental health difficulties than did the controls. They also showed greater sensitivity and empathy towards people experiencing mental health difficulties. There was a significant reduction in the conduct problems sub-scale and an increase in the pro-social sub-scale of the Strengths and Difficulties Questionnaire in the experimental group when compared to the control group. These results suggest that the introduction of a relatively short mental health component into the educational curriculum of secondary school-children can make a significant positive impact on both the knowledge and behaviour of those who receive it, at least on a short-term basis. Contact: Roehampton University of Surrey Prof Helen Cowie School of Psychology and Therapeutic Studies West Hill UK-London SW15 3SN Tel: +44 20 8392 3510, fax: +44 20 8392 3610 e-mail: [email protected] Web site: http://www.peersupport.co.uk, http://www.savecircle.co.uk

United Kingdom

The Foster Carers’ Training Project 1. Brief description of the project The main aim of this training programme is to help foster carers develop their skills in communication and increase their confidence in their ability to cope with their foster child’s feelings and behaviour. It was a mainly consultative training in style with some didactic input but with discussion and dialogue being the main vehicle for learning. This was based on principles of adult learning, acknowledging that carers would bring with them their own experiences, knowledge and skills, particularly about caring for children, too be harnessed and developed. 2. Aims of the project This project aims at improving attachment disorder symptoms, self-esteem and symptoms of other forms of child psychopathology including conduct problems, peer relations, depression, anxiety and hyperactivity. One of the long-term goals is to reduce foster placement breakdown and hence to reduce a range of social outcomes such as homelessness. 3. Method of Intervention A 3-day training programme was organised focussing on attachment, separation and loss and based on the Save the Children Manual “Children in Difficult Circumstances – Helping children in distress” written by Naomi Richman. Didactic material was presented by social worker Clare Devine, the foster carers were asked to use their own case material for discussion in a consultative model. 4. Duration of the project The intervention was a 3-day training programme with two concurrent days and the third day one week later. Trial participants were contacted just before the training, immediately after and 9 months later. 5. Target group/Participants Any family who fostered children aged 5 to 16 and where the child was likely to be with the foster family for at least one more year.

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6. Co-operation/Participants’ involvement 160 families were randomised to either training or standard services. 57 families, with 76 children, were offered training. 15 families with 20 children failed to attend. Foster carers took part in a focus group, the results of which informed development of the training programme. All participants were involved in feedback seminars and their comments incorporated into the discussion of the results. 7. Outcomes of the project There was a 4% improvement in symptom scores for psychopathology according to foster carers costs in the intervention group compared to the control group, a 12% improvement in symptom scores for psychopathology according to teachers costs in the intervention group compared to the control group, 14% of improvement in symptom scores according to children themselves. There was a 6% improvement in symptom scores for Reactive Attachment Disorder according to foster carers costs, a 2% improvement in self-esteem and a 35% increase in costs in the intervention group compared to the control group. Contact: Institute of Psychiatry/University of Glasgow Dr. Helen Minnis University of Glasgow Department of Child and Adolescent Psychiatry Caledonia House Yorkhill NHS Trust Glasgow G3 8SJ Tel: +44 141 201 0221 Fax: +44 141 201 9261 E-mail: [email protected]

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ANNEX 3: LISTING OF ALL OTHER PROJECTS RECEIVED COUNTRY PROJECT DESCRIPTION OBJECTIVES CONTACT Belgium

Self-help groups for people with a bipolar illness or people who suffer from frequent, long-term depression (bipolar II)

The project was set up by a few patients who met in a hospital. Every month, regional meetings are organised within the different self-help groups: a) information lectures by professionals (psychiatrists, psychologists, lawyers, etc.), b) discussions on topics concerning manic-depressive (bipolar) disorder and depression, c) book reviews on publications concerning the illness and d) the viewing of film concerning manic depressive disorders and depression. The new aspect is that young people should be reached as well. Patient go to schools and talk about their illness as well as about their experiences.

- to provide information to their members about the illness so they realise when they are going into a period of depression and can take direct contact with their specialist so that medication can be adjusted - to prevent hospitalisations or at least reduce the time of hospitalisation - to reduce the number of suicides

Flemish Association for Manic Depressives Bredestraat 55 B-9300 Aalst Tel:+32-53 77 50 97 e-mail: [email protected] Contact person: Michiels Jan e-mail: [email protected]

Finland

The Efficient Family: an intervention study on the prevention of mental disorders in children with mentally ill parents

This is a prevention of depression project targeted at children with mentally disturbed parents.

- to prevent transmission of depression across generations - to provide the health care system with efficient means to prevent children’s disorders when the parent(s) are mentally ill

The National Research and Development Centre for Welfare and Health Lintulahdenkuja 4, FIN-00530 Helsinki Tel: +358-9-39671 Fax: +358-9-3967 2155 Contact person: Tytti Solantaus, Maarit Alasuutari e-mail: [email protected], [email protected] Web site: http://stakes.fi

Germany

Media Suitcase

This project aims to raise awareness in schools and to improve the knowledge about mental illness among teachers and pupils.

- to reduce stigma and isolation - to increase awareness and knowledge

Landesverband der Psychiatrie-Erfahrenen Rheinland-Pfalz e.V. Schlesierstr. 46b D-6552 Diez Tel: +49-6432-3194 Fax: +49-6432-624181 Contact person: Eckhard Bauer e-mail: [email protected]

Greece

A school based mental health prevention and promotion programme for adolescents

This project is based on strategies developing communication skills and uses a combination of cognitive elements and a group dynamic approach. It develops the adolescent’s ability to take care of him-/herself and to assume responsibility. The intervention method used is a combination of counselling, skills training and group therapy practices.

- to increase adolescents’ self-esteem - to screen ‘vulnerable” adolescents and make the appropriate intervention - to train teachers in communication skills and mental health issues

Mental Health Centre of Athens 2 Zaimi Street GR-10683 Athens Tel: +30-10-3840413 Fax: +30-10-8232833 Contact person: Dr. A Diamantopoulos

Greece

Early recognition of mood disorders (major depression and dysthymia) in pupils of primary and secondary education

The project consists of two courses for teachers (total duration = 6 weeks). The intervention method used is mainly skill training for teachers. It consists of group meetings, which

- to increase awareness, sensitisation and the level of knowledge in teachers in order to be able to recognise and manage symptoms of mood disorders in pupils. – to be

Association for Psychosocial Health of Children and Adolescents (APHCA) 19 Agh. Ioannou Theologou ST 155 61 HOLARGOS Attica Greece

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include brief lectures/introductions, role playing by the participants and group discussion.

able to handle children and adolescents with mood disorders (either help them in the classroom and/or refer them to mental health services for treatment)

Tel: +30-1(0)-654 6524 Fax: +30-1(0)-6522396 Contact persons: Prof. J. Tsiantis & Dr. G. Kolaitis e-mail: [email protected]

Iceland

Health Promoting Schools - Iceland

This is a three-year project aiming at enhancing the health and well being of all in the school community. It is a joint project of the Ministry of Education, Science and Culture, the Ministry of Health and Social Security and the Directorate of Health. A supportive and encouraging atmosphere is created in the schools, making the transfer from one school level to another less stressful.

- to increase the consciousness and interest of teachers and pupils in promoting health and places high importance on working together with the parents and the community.

The Ministry of Education, Science and Culture Sölvhólsgata 4 150 Reykjavik Iceland Tel: +354-545 9500 Fax: +354-562 3068 Contact person: Anna Lea Björnsdó[email protected]

Iceland

Imago

The purpose of the project was to enhance self-esteem in young people since low self-esteem correlates with depression an anxiety, high-school drop-out, drug abuse, misery and the fact that low self-esteem prevents the person from being able to use his/her full potential. The strategy used is peer education and media campaigns.

- to make young people aware of their self-esteem and what influences it - to motivate them to enhance their self-esteem and teach them how to do that

The Icelandic Mental Health Promotion Project Tunagata 7 IS-101 Reykjavik Tel: +354-570-1704 Fax: +354-570-1701 Contact person: Dóra Guðmunsdóttir e-mail: [email protected]

Italy

School Project

Based on an Irish and a Welsh project, this is a project that enables the sufferer to realise his/her trouble and to motivate him/her to see a professional.

- to increase knowledge about the disorders describing the main symptoms and the possible consequences - to reduce stigma, favouring early detection of the trouble and early treatment, thereby reducing the risk of chronic development

Fondazione IDEA Via Statuto 8 I-20121 Milan Tel: +39-02-65 39 94 Fax: +39-02-65 47 16 Contact person: Prof. Paolo Lucio Morselli e-mail: [email protected]

Netherlands

Step by Step

This project is based on the “Coping with Depression Course” (see “Best Practices”) and is a cognitive behaviour therapy for depression. The project consists of reading materials, exercises, home work, etc. This version is especially designed for adolescents.

- to prevent depression in order to have a better chance of a social career and a higher level of psychological comfort

Trimbos-instituut Postbus 725 NL-3500 AS Utrecht Tel: +31-30-297 1100 Fax: +31-30-297 1111 Contact person: Janet Kramer e-mail: [email protected]

Netherlands

I am the Key (IATK)

This project is based on a programme first developed in primary schools in Israel. It was further implemented in International primary education and in primary schools in the Netherlands. It focuses on self-concept, self-esteem, coping skills and social support and is

The main goal is to promote mental health and reduce the risk of mental disorders and social problems such as symptoms of depression and aggression. The project aims to foster positive and realistic self-esteem, coping skills, and

Maastricht University Stategaard 27 NL-6227GL Maastricht Tel: +31-43-3619609 Fax: +31-43-3612071 Contact person: Michal Mann e-mail: [email protected]

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composed of three units: group building, inner self-processes and social support.

social support.

Netherlands

Enjoying School

This summer course is aimed at children of the age of 12 who are being bullied and/or experience problems in the interaction with other children. With the aim to avoid that these children start off on a wrong footing in secondary education, they receive a two days’ training about standing up for yourself and interacting with others during the summer holidays.

- to prevent the child in secondary education from the same problems as he/she encountered in primary education - to have a good start (self-image/attitude) - to reduce the chance of serious psycho-social and mental issues, such as anxiety, depression, criminality, addiction, etc.

RIAGG Noord-Limburg Postbus 242, NL-5900 AE VENLO Tel: +31-77-3550 202 Fax: +31-77-3543-604 Contact person: Henk Verstappene-mail: [email protected]

Netherlands

Early prevention programme for babies of depressed mothers

Project on the development and evaluation of a preventive intervention for depressed mothers and their babies (0-10 months)

- to improve positive and sensitive responsiveness of the mother and to improve positive exchanges between mother and infant aged between 0-10 months - to prevent children of a depressed mother from developing psycho-social problems and mental disorders

RIAGG Ijsselland Postbox 390 7400 AJ Deventer Tel: +31-570-688 788 Fax: +31-570-688 799 Contact person: Karin van Doesum e-mail: [email protected]

Netherlands

Tackling Depression

Project based on the “Coping with Depression Course” (see “Best Practices”), originally developed in the US. This version is a minimal intervention, a self-help course in the form of biblio-therapy.

- to increase self-esteem and reduce depressive symptoms, to improve coping skills - to prevent depression

Trimbos-instituut Postbus 725 NL-3500 AS Utrecht Tel: +31-30-297 1100 Fax: +31-30-297 1111 Contact person: Godelief Willemse e-mail: [email protected]

Norway

Sesam – a psychiatric school project

The basic idea behind the project was to ensure a secure basis for both the small community and the mentally disordered, when coming to stay at the small district psychiatric institution. The project aims at creating a better understanding and tolerance of the local inhabitants to the district psychiatric institution and the users.

- to reduce bad attitudes towards mental diseases and mental illness and also to reduce prejudices and to reduce the stigma associated to mental illness - to make the pupils understand what a mental illness is, and - to create arenas where users of the institution, pupils and the school staff can meet and exchange experiences and knowledge.

Rådet for psykisk helse Storgata 10A 0155 Oslo Norway Tel: +47-23103877 Fax: +47-32103881 Contact person: Sunniva Ørstavik e-mail: [email protected]

Norway

Patients have children too

Experience and various surveys show that adult psychiatric wards have little to offer to children whose parents are admitted to the hospital. The hospital staff is given advice on how to communicate with these children and how to encourage them to talk. Advice is also provided on how to improve the co-operation between the

- to make sure that children are cared for when their parents are admitted to acute psychiatric wards. - to prevent these children from developing a mental illness - to reduce the stress and fear of the parents as to how their children are being taken care of by the professionals - to offer information,

Blakstad hospital Box 143 N-1371 Asker Tel: +47-66 751571 Fax: +47-66901360 Contact person: Elin Kufås e-mail: [email protected]

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hospital professionals and the services in the community.

support and help to children regarding mental diseases

Norway

You are not the only one

Project encouraging both children/adolescents and their parents to attend counselling classes together to discuss problems in relation to carrying out parenthood.

- to prevent children of mentally ill parents from developing psycho-social problems and mental disorders

Blakstad hospital Box 143 N-1371 Asker Tel: +47-66 751571 Fax: +47-66901360 Contact person: Elin Kufås e-mail: [email protected]

Norway

Mental Health among young people in the county of Nord Trøndelag

This project falls outside the scope of our project but is still an interesting initiative. It was carried out by the National Organisation for Public Health. It aimed at mapping psychological problems and general quality of life, differences amongst the genders and to identify both risk factors and protective factors concerning psychological difficulties. It is based on a previous mapping exercise carried out for the whole of Norway for adolescents aged between 13 and 17.

- to study gender differences regarding life quality and identify both risk and protective factors concerning the mental health of adolescents in Nord Trøndelag - to estimate the prevalence of genetic and environmental factors for different aspects of mental health

Rådet for Psykisk helse Storgata 10a 0155 Oslo

Norway

Diagnosis Human Being

This project falls outside the scope of our project but is still an interesting initiative. EO is a student organisation for pupils aged 16-19 in Norway. Every year, EO is in charge of the “autumn campaign”. Usually, the focus is on school political issues. “Diagnosis Human Being” was launched in 2001. The main aim of the campaign was on the psychosocial context of learning in schools. The project lasted one day for each school that wanted to attend the campaign. 10.000 pupils from the local school councils from all over the country went through training on how to organise and carry out the campaign.

- to put mental health on the agenda - to get rid of prejudices and taboos concerning mental health in schools and in the community - to stimulate discussions concerning the responsibility of the school in terms of prevention or the responsibility on behalf of the school as a main cause or reason of why young people suffer from emotional distress - to raise awareness among students and teachers about the amount of problems amongst young people in schools

Mental Helse Norge (MHN) Postboks 298, Sentrum N-3701 Skien Tel: +47-35 58 77 00 Fax: +47-35 58 77 01 Contact person: Hanne Tangenese-mail: [email protected]

Spain

Adolescents’ programme

This is a Community Project for health care and promotion among adolescents. It was developed using three strategies: support, education and dissemination. Strategies used include health promotion campaigns with letters, leaflets, posters and hand-outs distributed in schools, social facilities.

- to increase adolescents’ self-esteem - to improve coping skills - to reflect on changes in adolescence - to contribute to a healthy development

Ayuntamiento de Madrid C/Navas de Tolosa n°10 E-28013 Madrid Tel: +34-91-5889680 Fax: +34-91-5889681 Contact person: Juan Madrid Gutiérrez e-mail: [email protected]

Spain

Helping to grow

This is a Community Project for Parent Education with the aim to support parents and to help their children

- to increase self esteem, to improve coping-skills and to reflect on what it means to be a parent

Departamento de Prevención y Promoción de la Salud Ayuntamiento de Madrid C/Navas de Tolosa n°10

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develop in a healthy way. It uses group, dynamic and active techniques. It is organised in schools, with different groups for each school stage.

- to support parents in their parental role - to enable parents to improve their children’s health

E-28013 Madrid Tel: +34-91-5889680 Fax: +34-91-5889681 Contact person: Teresa Benitez Robredo, e-mail: [email protected]

United Kingdom

Norfolk Family Support Teams

This initiative falls outside the scope of our project but is still an interesting initiative. The project came about following a national thematic review of child mental health services (CAMHS) “Together we stand” Health Advisory Service 1995 and a local needs’ analysis undertaken by the (former) Norfolk Health Authority. Norfolk’s Board recommended a pilot project to develop an accessible service delivery model for early intervention in localities. The current programme (2002) is based on the evaluation and outcomes of a project undertaken in Norfolk, and the recommendation of the HAS Report.

The programme was designed to promote the development of an early intervention service model in child mental health, in primary care settings. The aim was to test the hypothesis that such a service would have a positive impact on the waiting lists and referrals to specialist child mental health clinics. It would also influence, over time, the referral patterns from primary care to appropriate services in a timely manner. It would also increase the knowledge of primary care professionals about child mental health.

Norfolk Social Services Department The Pineapple 63 Bracondale Norwich Norfolk England NR1 2EE Tel: +44-1603-224338 Fax: +44-1603-223955 Contact person: Gregory Dawn E-mail: [email protected]

United Kingdom

Life Skills Education (as promoted by WHO) in Northamptonshire schools

This project is based on the WHO programme for mental health “Life Skills for psychosocial competence, adapted for use in schools to implement personal, social and health education and citizenship programmes already in use in schools as part of the National Curriculum. The training is for teachers and learning assistants in schools and school nurses in those schools to help them identify, plan for and ensure consistency in the delivery of Life Skills lessons and opportunities outside the school timetable, as well as opportunities within other curriculum areas.

The long-term goals are the improvement of the learning climate and interpersonal relationships in the whole school, with a corresponding reduction in behavioural problems and tension and stress in pupils and teachers.

Project Management Team, The Paddocks Manor Farm Rushden Road Wymington Rushden Northants NN10 9LN Contact person: Judith Coley e-mail: [email protected]

United Kingdom

Anxiety Clinic

This initiative falls outside the scope of the project but is still interesting. It is the only specialist Child and Adolescent Anxiety Disorders clinic in London. This is not a single programme, but a number of interlocking programmes involving treatment, treatment evaluation, identification of risk markers and factors for the development of anxiety disorders and associated conditions, such as depression, and proposed research on the reduction of some risk.

- to offer specialist cognitive behavioural treatment for children and adolescents with anxiety disorders - to conduct research into the causes, treatment, and prevention of childhood anxiety disorders - to disseminate CBT for anxiety disorders - to work with and support relevant voluntary sector organisations.

Department of Psychology Institute of Psychiatry De Crespigny Park London SE5 8AF

This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of thecontractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarilyrepresent the view of the Commission or the Directorate General for Health and Consumer Protection. The EuropeanCommission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use madethereof.

MENTAL HEALTH EUROPE - SANTE MENTALE EUROPE

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