Art & science mental health

A parent information leaflet to promote mental health in children McClintock C et al (2014) A parent information leaflet to promote mental health in children. Nursing Standard. 28, 51, 43-50. Date of submission: September 2 2013; date of acceptance: April 22 2014.

Abstract Positive mental health is an essential element of every child’s overall health and lays the building blocks for mentally healthy adults. There is increasing emphasis on childhood mental health as a public health issue. Nurses should be able to provide parents with clear, practical and accurate information to promote and maintain positive childhood mental health. This article describes the background to, and development and piloting of, My Mind Matters Too, a parent information leaflet promoting positive mental health for young children. The leaflet cannot operate in a vacuum but must be combined with other services and interventions if it is to bring about changes in the often complex area of childhood mental health.

Authors Carla McClintock Staff nurse, Belfast Health and Social Care Trust, Belfast. Bernie Reid Lecturer, School of Nursing, University of Ulster, Derry/Londonderry. Jackie Wade School nurse, Western Health and Social Care Trust, Derry/Londonderry. Correspondence to: [email protected]

PUBLIC HEALTH IS defined by Acheson (1998) as the art and science of promoting health, preventing ill health and prolonging life through the combined efforts of individuals, families, communities and society. Prevention of ill health is concerned with identifying and reducing risk factors for ill health, while health promotion seeks to make it possible for people to have greater control over, and improve their health (World Health Organization (WHO) 1986, 2002). Prevention of ill health and the promotion of health have traditionally focused on adults. More recently, childhood immunisations and child-specific treatments have been introduced, with new technologies offering prevention and cure of ailments (Palfrey et al 2005). Despite these successes, challenges have emerged, including socioeconomic influences on health such as poverty, health disparities, overweight and obesity and increasing concerns over mental health. Child mental health has become a major area of concern (Belfer 2008).

Keywords Child mental health, mental health, mental health nursing, public health

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Importance of childhood mental health There are many terms used to describe the mental health of children, including psychological wellbeing, emotional literacy and mental health disorders (Weare 2004). Zeanah et al (2005) further highlight the importance of distinguishing between mental health and mental ill health. For children, mental health is of vital importance not only because it enables optimal enjoyment of childhood but also because it lays the building blocks for mentally healthy adults (Council of Australian Governments 2009). Positive mental health is linked to improved physical health and longer lifespan (Chida and Steptoe 2008), enhanced psychosocial functioning (Keyes 2007), improved learning (National Institute for Health and Care Excellence 2008) and reduced risk-taking behaviours (Richards and Abbott 2009). Poor mental health during childhood can predispose to ongoing mental health

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Art & science mental health problems in adulthood (Kessler et al 2005). It is associated with a number of poor adult outcomes, including increased levels of antisocial behaviour and poorer socioeconomic status (Fergusson et al 2005).

Extent of childhood mental health problems Determining the global epidemiology of childhood mental health disorders is challenging. Reporting systems are often inadequate, recognition of disorders varies and the cultural component of mental health and ill health is only now being fully appreciated (Ford 2008). One international review of the extent of mental health disorders in children and adolescents from community-based surveys demonstrates that approximately 25% of this population experienced a mental health disorder during the previous year, and almost 33% in their life time (Merikangas et al 2009). Another study, performed over a ten-year period, estimated around 12% of children and adolescents in the United States experienced a functionally impairing mental health disorder (Merikangas et al 2009). A UK study conducted in 2004 reported that 10% of children and adolescents aged 5-16 years had been diagnosed with a mental health disorder in Great Britain (England, Scotland and Wales). Table 1 provides further details (Green et al 2005). The Bamford Review of Mental Health and Learning Disability (Northern Ireland) (2006) acknowledged that little epidemiological investigation of child mental health had been undertaken in Northern Ireland. Rates of many mental health problems in the region have been extrapolated from international and national studies. One estimate is that, given a 10% prevalence, almost 45,000 children aged

5-16 years in Northern Ireland will experience moderate-to-severe mental health problems requiring intervention from child and adolescent mental health services (CAMHS) (Green et al 2005). There are issues unique to Northern Ireland, which means that relying on data from other countries may be misleading. The extent and nature of the effects of the Troubles – more than 3,600 people were killed and tens of thousands injured during a period of sectarian conflict between 1969 to 1998 – on the population’s mental health requires further investigation (Macdonald et al 2011). In addition, Northern Ireland has higher levels of multiple deprivation than the rest of the UK (Poverty and Social Exclusion 2014), high levels of unemployment, benefits claimants, crime, free school meals entitlement, poorer educational attainment, and lower average wage and life expectancy (Marshall and McBurney 2010). The mental health burden in Northern Ireland is high, with approximately 39.1% of adults likely to experience at least one mental health disorder during their lives (Bunting et al 2012). As a result of high levels of social deprivation and the increased prevalence of mental health problems in the population, children in Northern Ireland may be at increased risk of mental ill health (The Regulation and Quality Improvement Authority 2011).

Factors affecting childhood mental health Epidemiological studies have helped to identify factors that can affect the mental health of children. These factors can be divided into protective and risk factors. The former moderate the effects of exposure to risk and the latter increase the probability of problems occurring. Longitudinal birth cohort studies

TABLE 1 Prevalence of childhood mental health disorders in Great Britain in 2004 5-10 year olds Boys

Girls

11-16 year olds All

Boys

All children

Girls

All

Boys

Girls

All

Type of disorder

Percentage of children with each disorder

Emotional

2.2

2.5

2.4

4.0

6.1

5.0

3.1

4.3

3.7

Conduct

6.9

2.8

4.9

8.1

5.1

6.6

7.5

3.9

5.8

Hyperkinetic

2.7

0.4

1.6

2.4

0.4

1.4

2.6

0.4

1.5

Less common

2.2

0.4

1.3

1.6

1.1

1.4

1.9

0.8

1.3

Any

10.2

5.1

7.7

12.6

10.3

11.5

11.4

7.8

9.6

(Green et al 2005)

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have been used to examine risk factors and follow the course of mental health in children. The Christchurch Health and Development Study, for example, followed a birth cohort of 1,265 children to the age of 21 (Fergusson and Horwood 2001). Investigation of causal links between specific mental health disorders and risk factors examined during this study included reduced parental workforce participation, lower family income and living standards, and lower childhood educational achievement. Results showed that combinations of these risk factors conspired to increase the risks of the development of mental health disorders during childhood, adolescence and early adulthood (Fergusson and Horwood 2001). More recent literature also suggests that childhood mental health is influenced by the complex interplay of the child’s characteristics as an individual with the characteristics of caregivers, family environment and wider socioeconomic and cultural contexts. Research findings report, for example, an association between mental ill health in children and physical illness (Hysing et al 2007) or parent physical illness (Barkman et al 2007), family breakdown (Amato 2001), parental alcohol misuse (Diaz et al 2008), young age of mother at time of first birth (Hofferth and Reid 2002), parental mental health problems (Whitaker et al 2006), societal turmoil and conflict (Garralda and Raynaud 2008), and socioeconomic disadvantage (Bradley and

Corwyn 2002). Increased risk of mental ill health is linked to deprivation, with 12-15% of children from very low income families experiencing mental health problems compared with 5% of children from very high income families (Green et al 2005). The greater the number of risk factors to which a child is exposed, the greater the likelihood he or she will experience mental ill health (Lawrence et al 2004). The interplay of risk and protective factors is further complicated by the clustering of risk factors – that is, exposure to one risk factor, for example lone parenting, increases a child’s vulnerability to additional risk factors, for example socioeconomic disadvantage (Ruchkin et al 2008). However, such clustering of risk factors does not necessarily lead to mental ill health, because a combination of protective factors can negate the adverse effects of risk (Zeanah and Zeanah 2001). Some children display resilience when faced with serious risk factors, a fact that points to the positive effect of protective factors (Table 2).

Promoting childhood mental health A public health approach should consider both protective factors for mental health and risk factors for mental ill health, together with the evidence base for prevention and promotion interventions. Examples include Sibley and Etnier’s (2003) quantitative review

TABLE 2 Protective factors that may prevent the development of mental health problems in children Individual factors  Easy temperament.  Adequate nutrition.  Attachment to family.  Above-average intelligence.  School achievement.  Problem-solving skills.  Internal locus of control.  Social competence.  Social skills.  Good coping style.  Optimism.  Moral beliefs.  Values.  Positive self-related cognition.  Good physical health.

Family factors

School context

 Supportive, caring parent.  Family harmony.  Secure and stable family.  Small family size.  More than two-year age gap between siblings.  Responsibility demonstrated in the family.  Supportive relationships with adults other than parents.  Strong family norms and morality.

 Sense of belonging.  Positive school culture.  Peer group that ‘benefits’ the child.  Requirement to demonstrate responsibility and helpfulness.  Opportunities for some success and recognition of achievement.  School norms that discourage violence.

Life events and situations  Involvement with significant other person such as a mentor.  Ability to adapt at critical turning points or major life transitions, for example, family breakdown.  Parental or family economic security.

Community and cultural factors  Sense of connectedness to others in the community.  Attachment to and networks in the community.  Participation in church or other community groups.  Strong cultural identity and ethnic pride.  Access to support services.  Community and/or cultural norms that discourage violence.

(Adapted from Commonwealth Department of Health and Aged Care 2000)

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Art & science mental health demonstrating a significant positive relationship between physical activity and cognitive function in children, a meta-analysis from De Graaf et al (2008) outlining the benefits of parenting programmes to promote child health, and Anderson et al’s (2003) systematic review of the positive outcomes derived from pre-school programmes promoting cognitive, social, health and family aspects of child development. An analysis of 27 systematic reviews advances the argument for preferential provision of early interventions to promote positive mental health and prevent mental ill health in children. Early interventions may include self-development, anxiety and depression prevention programmes, and anger and violence management programmes, including school-based initiatives. The evidence points to the effectiveness of a range of mental health-promoting interventions in reducing mental ill health (Barlow et al 2007). Policy-making is essential to enable translation of knowledge into actual provision of help. One survey revealed an international paucity of clearly defined children’s mental health policies (Shatkin and Belfer 2004). The WHO (2005) reflects the long-held view of the United Nations (UN) Convention on the Rights of the Child (UN General Assembly 1989) that appropriate access to preventive programmes and the fulfilment of a mentally healthy life is insufficient. The UK context seems more favourable, with numerous policies promoting a child-centred approach explicitly outlining requirements for mental health provision (Every Child Matters (Department for Education and Skills 2003); National Service Framework for Children, Young People and Maternity Services (Department of Health 2004)). However, although mental health promotion is on the ‘agenda’, many policies are merely aspirational because there is little investment in mental health promotion (Children and Young People’s Mental Health Coalition 2010). In Northern Ireland, the wider context for children’s services is framed by the ten-year strategy for children, Our Children and Young People – Our Pledge (Office of the First Minister and Deputy First Minister 2006), a strategy underpinned by 11 core values (Box 1). Other relevant documents include Families Matter (Department of Health, Social Services and Public Safety (DHSSPS) 2009) and Healthy Child, Healthy Future (DHSSPS 2010). These documents have a common overriding concern: recognition of enabling children to maximise their potential. Many determinants of positive mental health lie outside the remit of the health sector.

The Promoting Mental Health: Strategy and Action Plan document therefore recognises mental health promotion as a cross-sectoral responsibility (DHSSPS 2003). This echoes a strategy laid out in the Ottawa Charter for Health Promotion to ‘strengthen community actions’ (WHO 1986). Community and voluntary organisations have important roles in linking with and providing services to children. Strong social cohesion is associated with the promotion of wellbeing and resilience, and initiatives such as Health Promoting Homes offered in Northern Ireland provide an example of community-organised action addressing community health needs (O’Hara 2005). The WHO suggests schools should play an influential role in promoting children’s mental health (Tang et al 2009). Health surveillance and illness prevention, as opposed to treatment, have been at the forefront of school nursing for many years. School nurses’ responsibilities include assessment, health promotion, early intervention activities and signposting or directing children and their families to other relevant agencies and support services. One study of school nurses in the UK found that, although 93% of nurses agreed mental health was integral to their role and 55% stated that dealing with schoolchildren’s psychological problems took up more than 25% of their time at work, 46% had not undertaken any post-registration training in mental health (Haddad et al 2010). School nurses in England were found to value their role in the

BOX 1 Core values of Our Children and Young People – Our Pledge All children and young people:  Have dignity as human beings and are respected.  Have rights as individuals.  Need loving and supportive families or carers.  Are unique individuals each with a valuable and diverse contribution to make to society.  Are active participants in society.  Are important in their own right, both now and in the future.  Are entitled to adult protection and opportunities to exercise their independence.  Are entitled to live in a peaceful and non-threatening environment.  Are entitled to educational opportunities.  Need support to explore and achieve their individual potential.  Need support and encouragement through transition from childhood to adulthood. (Office of the First Minister and Deputy First Minister 2006)

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mental health care of young people, viewing this as an important aspect of practice (Pryjmachuk et al 2012). However, several barriers to their work in this area were identified, including limited educational training opportunities, a lack of confidence and heavy workloads. Professional rivalries with teachers and other school staff, often because of lack of understanding of roles, also detracted from effective healthcare delivery.

Developing My Mind Matters Too In the light of the need to promote positive mental health in childhood, it was decided to develop a parent information leaflet, My Mind Matters Too. This was thought to be a good way to meet individuals’ need for quality, accurate and easily accessible health information (Duman 2003). Leaflets enable individuals to learn in their own time and at their own pace (Sharry et al 2002), and improve retention of information (Macfarlane et al 2002). At the time of development, there was no comparable leaflet available in Northern Ireland. This information leaflet (Figure 1) was developed to help parents identify what positive mental health entails and its importance in child development. It also aimed to describe a range of practical activities that parents could perform to promote positive mental health in young children. All health promotion activity should be underpinned by theory, systematically developed, piloted and delivered, and evaluated robustly (Needle et al 2011). Development of My Mind Matters Too was underpinned by the Health Belief Model (Rosenstock 2005) in that the leaflet aimed to provide a ‘cue for action’ or behaviour change by seeking to affect parents’ beliefs about the cost of, or susceptibility to, mental illness during childhood as well as the benefits of practical activities to promote positive mental health. Development of the leaflet also reflected a universal approach to health promotion – that is, targeting all parents of young children as opposed to those with children at greater risk of developing mental ill health (WHO 2002). Dixon-Woods (2001) identified two types of patient information leaflets: those that focused on patient education and those that focused on patient empowerment. My Mind Matters Too could be considered to combine both types by providing information (education), and empowering parents by providing them with simple steps that may be incorporated into their child’s day-to-day routine. Robertson (2008) cautions that the effectiveness of information leaflets relies on achieving a balance between the level of literacy,

FIGURE 1 Cover page of My Mind Matters Too

Positive Mental Health and the Young Child

Carla McClintock, University of Ulster

rcnpublishing.com/r/my-mind-matters

including health literacy, of the proposed audience and the readability of the leaflets. A systematic approach to the development of leaflets should be adopted and include: reviewing of existing research to ensure up-to-date and relevant messages are incorporated; using quality design formats that are attractive and clear; ensuring ease of readability; and pre-testing for level of interest, comprehension and relevance (Robertson 2008). Such an approach was adopted in developing and piloting My Mind Matters Too. The content of the leaflet aimed to benefit parents by presenting facts in a focused, objective and balanced manner. The content sought to discuss the ‘what, why and how’ of positive childhood mental health with respect to four main prerequisites: love and affection, healthy eating, keeping active and communication (Thompson et al 2012). Thus, information was structured in a logical and organised flow, moving from the general to the more specific. These prerequisites in the structure of the leaflet’s content enabled the provision of clear and practical information that could be incorporated by parents into day-to-day routines to promote positive mental health. Succinct sentences attempted to explain one single idea each, because this enables individuals

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Art & science mental health to integrate and store information. A conscious attempt was made to avoid the use of technical terms and jargon because 18 percent of the adult population in Northern Ireland is functionally illiterate (Oxford Economics 2010). To maintain the leaflet’s relevance, it was written to an average readability score of 60, using the Flesch Reading Ease Score Formula, calculated using the average sentence length in words and syllables, the percentage of commonly used words present and the percentage of words that use one or more syllables. Clear fonts were used on a light background to improve legibility, and illustrations were drawn using a cartoon style design.

My Mind Matters Too, pilot study It is important to pre-test patient information leaflets to ascertain levels of readability and comprehension, to understand the contextual nature of leaflets and to evaluate the cognitive information processes required to understand them (Gal and Prigat 2005). In piloting this leaflet, contact was made with family support workers from three local ‘healthy living centres’, local programmes aimed at addressing the health needs of the most disadvantaged, and this enabled access to parents of young children. Thirteen parents, all mothers, agreed to participate in piloting the leaflet. Cognitive interviews were conducted at each of the healthy living centres with groups comprising four or five mothers. Cognitive interviewing lends itself to pre-testing written materials including parent information leaflets (Lake et al 2007). The technique uses ‘think aloud’ interviewing – led by the respondent, who verbalises his or her thoughts as they are introduced to and asked to read the leaflet – and ‘probing’ – led by the interviewer, who asks direct questions about comprehension, meaning, recall and judgement. ‘Think aloud’ is recognised as a challenging technique for respondents (Lake et al 2007). In piloting this leaflet, a ‘probing’ technique using both open and direct questions was used to make the interview easier and to provide more feedback (Box 2). In addition to the probing interview, parents were asked about the appearance of the leaflet, including text size, layout and illustrations. Interview notes were reviewed to ascertain areas of misunderstanding and where modifications to wording, content and layout were required. Parents’ wording resulted in the Flesch Reading Ease Score increasing from 60 to 66.5, indicating easier readability. Some parents disliked the use of bullet points because they perceived

BOX 2 Examples of questions used in the interviews  From looking at the front cover, what do you think this leaflet is going to be about?  What’s your understanding of the following words: mental health, positive mental health, stable and consistent relationships, healthy diet, physical activity, communication, interaction, evidence.  What do you understand by this sentence?  When you read this sentence what are you thinking?  How would you put this sentence in your own words?  What are you thinking while you read this?  What’s this sentence telling you?  Can you explain this sentence to me?  What will stick in your mind from this leaflet?

them as implying that the list needed to be followed. However, most parents viewed them as contributing to the overall clear layout of the leaflet. Bullet points were therefore retained. Parents’ comprehension of specific words or terms was explored by asking for their interpretation of the target word or term. Interviews established parents had a clear and unambiguous understanding of the term ‘positive mental health’, which was retained on the leaflet. However, some words were not understood by parents, or caused confusion. For example, the word ‘interaction’ was poorly understood, and parents preferred to use the words ‘communication’ or ‘talking’. Parents felt that the term ‘appropriate physical activity’ lacked clarity and that specific examples of physical activity were more helpful. Knowledge and understanding of positive mental health varied greatly, from parents who were well informed to those who were finding new facts about mental health in the leaflet. For example, some parents said they would not consider healthy eating as a prerequisite of positive mental health, whereas others thought the information contained in the leaflet offered a ‘common sense’ approach rather than something new. The leaflet did, however, raise awareness and generate discussion in the groups with, for example, one mother commenting: ‘My four-year-old won’t eat her dinner. She says that she is too fat. I thought that it was just a phase she was going through but now that I think about it, she did say that the kids at school are telling her this. I told her not to mind them but there may be a lot more going on in her wee head than I realise. I need to sort this out.’

Recent developments In follow-up to the pilot study, refinement of My Mind Matters Too has been undertaken in collaboration with the local health and social care

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trust. The trust has now adopted and printed the leaflet, making it available to parents through services such as health visiting, school nursing, SureStart, healthy living centres and other relevant agencies.

Conclusion Growing evidence supports the fact that the building blocks for positive mental health are laid down in the early years of childhood. Nurses have a role in providing parents with clear, practical and accurate information to promote and maintain positive childhood mental health. This article has outlined the process of developing and fine tuning My Mind Matters Too, a parent information leaflet promoting positive mental health for young children.

While time-consuming, the process enabled collaboration with a group of parents. Interventions such as My Mind Matters Too cannot function in a vacuum but must be undertaken with other services and interventions if they are to bring about large changes in the often complex area of childhood mental health. Refinement and evaluation of My Mind Matters Too is continuing, in collaboration with the local health and social care trust NS Acknowledgement My Mind Matters Too was developed during a public health practice-learning placement with school nursing services as an undergraduate student nurse (adult) in Northern Ireland. The project was a joint winner of the RCN Northern Ireland Nursing Student Award in June 2013.

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