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 group.
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, 2001
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 strategies
Targeted upon high risk groups
Advantages
Disadvantages
Population-based strategy
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.
