Prevent or treat

The Children’s Fund was launched in November 2000 as an
integral part of the government’s strategy for tackling
social exclusion among children aged between five and 13, and their
families. The key objective is the early identification of “at
risk” children and young people and to provide the help and support
they require.

The preventive focus of the Children’s Fund provides a
much-needed alternative to the restorative model that currently
dominates child services. Instead of providing services after
problems have become established, the Children’s Fund
provides an opportunity to creatively explore how high quality
preventive services can be tailored to meet the needs of local
communities before significant problems become evident. The danger
is that “preventive” will once again be interpreted as “targeted”
– and the opportunity to intervene in ways which genuinely
prevent problems developing will be lost.

Already guidance from the Children’s Fund suggests treatment
rather than genuine prevention.1 Only one of the four
levels of intervention described would be aimed at all children.
The other three are essentially concerned with treatment in terms
of preventing identified problems becoming more severe or
interventions designed to treat more established, significant and
complex problems.

Given the diversity of possible interventions that could be
considered preventive the question arises as to how preventive
programmes are best provided, and in particular whether they should
be targeted upon identified high risk groups or universally
provided to whole populations.

Targeted approaches focus on those who belong to groups that put
them at an increased risk of developing problems. In emotional
health there could be a number of factors relating to the child
(such as learning difficulties), their family (for example,
parental conflict/family breakdown) or their environment (such as
socio-economic disadvantage) that increase the risk of emotional
health problems developing.2 Preventive programmes could
be targeted upon these “at risk groups” and could, for example, be
provided for children attending special schools, for single parents
and upon a particular geographical area.

In contrast, universal preventive programmes are provided to all
in a particular group regardless of their level of risk. These
programmes usually work directly with children in order to teach
skills that will improve or promote their emotional and mental
well-being and foster the development of emotional resilience. They
could be provided to all children in a particular school year with
the programme being delivered through local schools.

An argument often voiced in favour of targeted approaches is
that they concentrate limited resources upon those at greatest
risk. In terms of emotional health, there are several factors that
will increase the risk of emotional problems developing so choices
will need to be made between which at-risk groups will be targeted
and which will not. The process of selection and targeting is
potentially stigmatising and problematic (particularly with
emotional health issues) and inevitably programmes often fail to
reach those in the high-risk group in greatest need.

Finally, targeted approaches aimed at specified at-risk groups
tend to overlook the potential benefits to those in lower risk
groups in terms of preventing significant emotional problems
developing and thus children progressing to the high-risk

In order to ensure resources are used to maximum effect it is
important to pay particular attention to the question of
effectiveness. However, it soon becomes apparent that while there
are many different ideas as to how the emotional health of children
can be promoted there is an absence of good data detailing the
effectiveness of many programmes. A review of preventive programmes
for emotional health was undertaken and identified several
important themes, which underpinned the development of the
programme in Bath and North East Somerset.3

The review highlighted the need for preventive projects to be
non-stigmatising and to focus upon the specific needs of children
at their particular life-cycle stage. Interventions at times of
transition were identified as more effective in that children were
often more “open” to interventions at this time. The need for
earlier interventions was recognised in that it is easier to alter
the behaviour of a primary school child than that of an adolescent.
Simply providing children with information is not sufficient.
Skills-based approaches whereby children are taught planning,
learning, problems solving, communication and social skills tend to
be more effective.

On the basis of this it was decided in Bath and North East
Somerset to adopt a non-stigmatising universal emotional health
preventive programme. The focus would be upon children undertaking
the transition to secondary school and would involve the teaching
of relevant and appropriate skills to enhance the child’s
emotional resilience. In terms of effectiveness, cognitive
behavioural treatment programmes are showing most promise and it
was decided to adopt an existing programme of proven effectiveness
rather than developing or extending a local initiative. This led us
to identify the Friends programme (see panel, left); one of the
better-evaluated universal interventions.

The Children’s Fund provides an opportunity to develop
innovative services that are preventive, but there is a danger of
prevention becoming synonymous with treatment. The tendency to
adopt targeted programmes fails to address the issue of which risk
group should be targeted.

1 Children and Young
People’s Unit, Children’s Fund Guidance, DfES,

2 Mental Health Foundation,
Bright Futures: Promoting Children and Young People’s
Emotional Health
, MHF, 1999

3 Rachel Smith,
Children’s Emotional Health, Barnardo’s,
unpublished, 2002

Dr Paul Stallard is a consultant psychologist at Avon
& Wiltshire Mental Health Partnership NHS Trust, and Dr Neil
Simpson is a consultant paediatrician at Bath and North East
Somerset Primary Care Trust.

Advantages and disadvantages of preventive

Targeted upon high risk groups


  • Appropriate to individuals concerned
  • Relatively high potential benefit to targeted individuals


  • Limited public health impact.
  • Often difficult to identify and engage with “high risk”
  • Effectiveness in reaching the target group depends on the
    screening tool used.
  • Effect is temporary and has to be repeated as new people enter
    the “high risk” category.
  • Poor recognition of wider influences on behaviour (eg peer
  • Feasibility and costs.

Population-based strategy

  • Potential benefit for whole population
  • Equal focus on all individuals regardless of risk status,
  • Potential to shift whole groups’ health norms and hence
    more radical long-term change
  • Reduced potential for stigmatisation.
  • Resources directed to those who may not be most in “need”.
  • Comparatively “low dosage” of the intervention may not be
    sufficient to help those at “high risk”.

Friendly sessions

Friends is a cognitive behavioural programme designed to prevent
anxiety and depression through the building of emotional
resilience. The programme is a 12-session group format that can be
used in schools with children aged seven to 11, or 12-16 years of
age. The programme covers a range of skills including emotional
literacy, positive coping and problem-solving skills. A number of
evaluations have been undertaken which demonstrate that up to 80
per cent of children who showed signs of anxiety no longer
displayed them after completing the programme, a benefit that
continued to be confirmed at a two year follow-up.



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