Evaluation of a Current Child Health Issue - Essay Example

?Childhood depression is a serious mental health condition which can potentially have long term effects on a child’s (Northen, 2004). This essay willcritically analyse current health promotion interventions aimed at supporting children with depression and how these impact on child care and educational practice. Then, based on research, recommendations will be made for further practice and research. The World Health Organisation (2004) predicts that by 2020, there will be a 15 per cent rise in the level of children’s mental health disorders (Northen, 2004). In 2008 at least 10 per cent of children and adolescents in the United Kingdom suffered from a health problem and the most common childhood mental health issues were anxiety and phobias (ibid). Depression, another emotional disorder, is also on the rise with young people with at least 2 per cent of children under 12 and 5 per cent of teenagers suffering from depression (op.cit.). Depression is associated with “feelings of extreme sadness” (NHS, 2010, para.6) which not only last for long periods of time, but is also recurrent and may further develop into suicidal tendencies (ibid). Brent and Birmaher (2002) noted that depression in both children and adolescents is not always demonstrated by sadness, but can take the form of irritability, boredom and the inability to find pleasure. Younger adolescents may show more anxiety-related symptoms, clinging behaviours, unexplained fears and physical symptoms, while older adolescents may experience a greater loss of interest and pleasure and also have more morbid thinking (Kalb & Raymond, 2003; Mondimore, 2002). Lewinsohn et al. (1998) found that nearly 89% of depressed adolescents reported disturbances in sleep. With younger children in the early childhood stage, depression is manifested by “masked” symptoms such as a complaint of stomach ache or aggression (Carlson & Cantwell, 1980; Hazel, 2002; Luby et al., 2003). These symptoms are fairly common in children, so it is not usually identified as a depressive symptom. However, when young children have these symptoms and are also seen to be irritable, bored or not finding pleasure, especially in play which is inherently fun, then they may present symptoms of early childhood depression (Brent and Birmaher, 2002). The difficulty with reaching a clear diagnosis of depression at this stage is that young children are perceived to be developmentally too immature to experience the effects of such a heavy emotion (Stalets & Luby, 2006). On the other hand, studies have shown that in fact children at this stage are far more emotionally sophisticated than they are given credit for (Denham et al., 2002; Denham et al., 2003; Saarni, 2000; Lewis et al., 1992; Lewis et al., 1989). Depression in very young children results in experiencing complicated emotions such as guilt and shame (Luby et al., 2009) and as younger children “mask” their depression it can be harder to identify a need early on. Some children who are depressed may actually avidly participate in activities with others such as singing and dancing and even exaggerate their actions. This makes diagnosis even harder and early intervention difficult. Depression can develop from a combination of different factors (risk factors) such as genetics, physiological, environmental and socio-economic factors such as parent’s unemployment , sickness and large families in small houses, bullying of peers or abuse from adults (Northen, 2004). If these risk factors are already present in the child’s life then significant life changes such as a death of a significant other, parental divorce and other tragedies will greatly increase the likelihood of childhood depression. One particularly important factor that affects a child’s likelihood of developing depression is the quality of their relationship with their family. Brofenbrenner’s Ecological model (1979) explains that family is part of the child’s microsystem and the primary providers of the child’s basic needs. The psychological and sociological influences of the microsystem have an effect on the young child. If conflict is not resolved in a constructive way in the microsystem, then children are likely to be involved, causing them to be psychologically vulnerable; the resulting tension and conflict induces emotional arousal that triggers physiological and psychological responses that may lead to depression (Wang and Crane, 2001). This is consistent with the findings of Stalets & Luby (2006) who found that young children may not be equipped with skills to help them deal with such stressors. Hazel (2002) claims that the child’s personality is a determinant in how they respond to such stressors; some children may be uninhibited in opening up to their parents about an issue bothering them, whereas others may keep unresolved issues to themselves. It is the latter who are vulnerable to depression although this is dependent on how parents relate to their children. Pomerantz (2001) used the Parent X Child Model of Socialisation to explain that when parents give intrusive support to their children it can result in the child seeing themselves in a negative light and being more vulnerable to depressive symptoms. Children with such parents would generally keep their thoughts and feelings to themselves rather than have their parents involved which potentially may make them feel worse. Also, if the parents are depressed then this can affect their children; child may feel emotionally overwhelmed which can result in defiant and rebellious attitudes and can also prompt depressed moods through modelling (Pomerantz, 2001). The young child may perceive that being depressed is the norm, hence, imitate and adopt their parent’s disposition (Sokolova, 2010). One newly-developed support therapy is the Parent Child Interaction Therapy-Emotion Development (PCIT-ED) developed by Eyberg (in press). It targets the child’s emotional skills and development of adaptive patterns of responding to various events experienced that may possibly lead to depression while teaching the caregiver or parent skills as the child’s external emotion regulator. While it is ideal that parents are involved in the therapy of their young children, it is worth considering if depressed parents will benefit from this therapy as well. Hence, it is important that the therapist is adept at intervention strategies for both child and adult. As previously discussed, it can be difficult to identify the symptoms of childhood depression and so adults need to be alert to observing a change in children’s behaviour which could potentially be related to depression. Early Years practitioners, who spend a lot of time with the children at school, are in a good position to help in the early identification of depression. They will be familiar with the children’s behaviours in the child centre as well as have information and access to the children’s family background and if there are significant changes that may affect the child. Head teachers and special educational needs coordinators (SENCO) are mandated by the government to coordinate help for individual children’s school-based needs (Appleton, 2000) and to approach the appropriate agency for support. One such agency is the Child and Adolescent Mental Health Services (CAMHS), which aims to promote the mental health of all children through a multi-tiered support approach (DfES, 2008). Tier 1 is concerned with the early identification of symptoms and it is at this level that school personnel would be involved to help identify children who may be showing signs of mental and emotional disorders. One recommended strategy at this level that schools endorse is the Social and Emotional Aspects of Learning programme (SEAL). This is “a comprehensive, whole-school approach to promoting the social and emotional skills that underpin effective learning, positive behaviour, regular attendance, staff effectiveness and the emotional health and well-being of all who learn and work in schools” (DCSF, 2007, p.4). SEAL may be included in the Personal, Social, Health & Economic (PSHE) education programme of schools where teachers plan developmentally-appropriate activities for children with the aim of developing their social and emotional competencies so they are strong enough to cope with challenges. PSHE education is delivered through discrete lessons. At the primary level, such lessons are followed by SEAL lessons, which are integrated in the curriculum as part of other subjects. Case studies showed positive outcomes of PSHE for students which includes their appreciation of opportunities to express their views and ask questions, learning about key issues that affect both their present and future lives, improvement in their social relationships, health and overall well-being. However, there is a need for a standardised structure for schools to follow because of the inconsistency of schools’ understanding of PSHE education and implementation (Formby et al., 2011). PSHE and SEAL are educational health promotion approaches as it teaches children directly how to be socially and emotionally capable (Whitehead,1995). SEAL also uses the Targeted Mental Health in Schools (TaMHS) Intervention Model under the recommendations of the National Institute for Health and Clinical Excellence (NICE) for the promotion of social and emotional well-being of children (DCSF, 2010). It builds on existing SEAL programmes and targets therapeutic work with children and families in three ‘waves’. Wave 1 involves the whole school promoting emotional well-being and mental health and the basic SEAL programme; wave 2 involves skills-focused interventions with small groups of children identified as needing help in developing their social and emotional skills and finally, wave 3 involves therapeutic interventions for individual and small groups needing a more intensive strategy. In all three waves, experts from outside the school who work in integrated children’s services facilitate the TaMHS sessions alongside school staff (ibid). Despite the noble intentions of SEAL, Humphrey, et al (2010) found that SEAL was not consistent in creating a significant impact on the students’ “social and emotional skills, mental health difficulties, pro-social behaviour or behaviour problems” (p.3). Some factors considered in its inconsistency are difficulties in the implementation of whole-school programmes with high expectations that it will bring about outcomes in the short-term, and when it did not deliver as soon, led to withdrawal of effort and interest. In order for both PSHE and SEAL programmes to succeed, more training for staff will implement them in schools, as well as more time to allow it to be imbibed by the students would be necessary to gauge its success and effectiveness in improving students’ social, emotional and mental health (Humphrey, et al 2010) The TaMHS shows much promise especially in terms of objectivity in diagnosis because in utilising external assistance, the element of unfamiliarity of personnel may be a hindrance to the easy establishment of trust from the children. Strangers coming into the school may cause some children to withdraw especially if the strangers question them on their social, emotional and mental issues. Dowdy et al. (2010) offer another health promotion school-based plan which does not need external staff but uses school-based mental health professionals who will identify children who are having difficulties in the school and ultimately provide services using school-based screening data to identify and monitor the mental health needs of students. School staff commissioned to handle this plan need to be well trained by professionals from the CAMHS. If they are not trained, these facilitators may cause more damage to the students. Having access to school records, and knowing the school officials makes it easier to facilitate changes. Such health promotion programme adheres to a societal health promotion approach (Whitehead, 1995) because it reflects how mental health is conceptualised within a society and that the illness of one affects the entire population, hence prevention for all is called for (Dowdy et al., 2010). Another health promotion strategy at Tier 1 is the No Health without Mental Health scheme which adopts a behavioural approach to health promotion. It promotes early intervention and strategies to develop children’s emotional resilience and self-esteem in very early childhood (Kidd, 2009). Resilience is one trait (protective factor) that is essential for positive mental health. Hence, it is believed that when children learn resilience, they easily overcome from feelings of sadness and maintain their regular functioning. The programme aims to help children be enabled to ‘bounce back’ and cope realistically with social or emotional issues that confront them. Since the target audience is very young children who may have short attention spans and can easily shift their emotions, there is a question as to whether it is the children’s natural resilience that is at work or if the is actually developing resilience. (Kidd, 2009; Luby, 2009; Saarni, 2000). A commonly used health promotion model is the Health Belief Model (HBM) which proposes that health behaviour is determined by one’s personal beliefs or perceptions regarding a disease or disorder and the available strategies one can access to prevent it. The four perceptions, namely: perceived seriousness, perceived susceptibility, perceived benefits and perceived barriers can be used to explain why a person behaves the way he does when it comes to health (Hayden, 2008). To apply to children with depression, such perceptions need to be influenced in a positive way through various activities interesting to them so that depression is prevented. For example, in explaining depression, educators can talk about sadness and how it can affect their moods and activities and what they can do to avoid being sad for a long time. Because they are young children, age-appropriate terms and explanation should be used. Educators can focus on the benefits of not being sad and how they can overcome barriers to being happy. In explaining these things well to children, perceptions of how they can achieve well-being are implanted in them. Activities can be the use of related storybooks and the teaching of songs with movements that have words to empower them against depression. These activities aim to strengthen their beliefs that they can combat depression in their own little way. Tier 2 is where multidisciplinary services are involved and coordinated by specialist CAMHS professionals. Since these professionals work with people of all ages, it is essential that they are also adept at handling cases involving very young children which is why training of healthcare professionals to deal with early childhood depression is another plan of No Health without Mental Health (2009). This health promotion strategy involving health care workers ensures knowledge and understanding of early childhood depression (Whitehead, 1995). Tier 3 provides multidisciplinary team services for special cases which have already been diagnosed in the lower tiers. Multi-agency working is essentially for bringing together practitioners with a range of skills to work across their traditional service boundaries (Every Child Matters, 2008). Children diagnosed with depression may work with psychologists, social workers, psychotherapists and paediatricians and this joint working has been found to accelerate the progress of children and ultimately contribute to their well-being. A review of school-based interventions in the UK to enhance children’s well-being suggested that schools play a valuable role in providing a base for multi-agency support for children and families within local communities (Pugh & Stratam, 2005). Pettit (2003) also reports measurable improvement of behaviour and peer relationships of children jointly helped by both school staff and CAMHS. The Children Act (2004) provides a wider strategy for improving children’s lives through joint working. “The overall aim is to encourage integrated planning, commissioning and delivery of services as well as improve multi-disciplinary working, remove duplication, increase accountability and improve the coordination of individual and joint inspections in local authorities” (DfES Children Act and Reports, 2004, p). This entails close collaboration between schools and concerned agencies, so issues of differences of opinions may surface. Having people from different backgrounds, qualifications and disciplines working together entails flexibility and adaptability to others. Practitioners bring with them their own professional training and credibility but when they become part of a multi-agency team, they may use this as a shield of security which may protect them when they are threatened. However, the common priority is the welfare of the child being helped and such differences must be put aside. There should be clarity of the particular roles each agency should take in the intervention and the NFER (2004) explains that the less replication between different service providers, the better the links between service providers including a much greater understanding of what each should contribute. Finally, Tier 4 is the provision of care for children with severe, complex and persistent disorders involving professional expertise in the treatment of early childhood depression (Appleton, 2000). Usually, psychological therapies are employed, which are client-centred approaches such as Cognitive Behavioral Therapy (CBT). The goal of CBT is to help the client realise that re-organising the way they view situations will call for a corresponding re-organisation in their behaviour (Beck, 1975). This behavioural health promotion strategy has shown to be beneficial for school-aged children (Whitehead, 1995), however, no clear model for extending effective treatments to early childhood populations is yet available (Luby, 2009). Jackson and Cohen (2007) have tried CBT for preschool children who have post-traumatic stress disorder; however, since the therapy has been on very young children and these children may have difficulty verbally expressing themselves or sharing the accounts of the interventions, it remains unclear if these interventions are really effective. Luby (2009) notes that because young children rely on their parents or caregivers for socio-emotional and adaptive functioning, a more effective approach may be parent-child psychotherapy. This implies that the significant people whom the troubled child may be reliant on for emotional support should be open to such treatment for themselves. If the parent or caregiver is in denial of the problem, then efforts of any intervention will be futile. Since depression in the early years has only been recently diagnosed, much research needs to be done in terms of identifying prevalent causes in early childhood. It has also been suggested in the literature that the symptoms of depression in early childhood are not readily identifiable. Hence, research on this would be significant in helping early years practitioners accurately detect children with depression. Factors that influence the development of depression should also be addressed, with the cooperation and support of the child’s family. Parents should also be targeted to gain awareness and understanding of childhood depression and be ably guided as to how to avoid it or prevent it from escalating further. 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