Prevention of mental ill health and poor emotional wellbeing predominantly works at three different levels:
- Primary prevention – Stopping mental health problems from occurring in the first place by using ‘upstream’ approaches.
- Secondary prevention – Identifying the earliest signs that mental health is being undermined and ensuring early intervention is available to minimise progression into a more serious mental health problem.
- Tertiary prevention – Working with people with established mental health problems to ensure the earliest path to sustainable recovery and to reduce the social, economic and health losses often resulting from living with a mental health problem.
The Mental Health Foundation suggest that an additional dimension should be built into this to allow for a progressive focus on those at highest risk:
- Universal: seeking to influence a whole population or groups within settings such as schools or colleges
- Selective: seeking to reach individuals or subgroups based on known areas of generally higher risk, including those who may not be showing signs of developing a mental health problem but live in circumstances known to be corrosive to mental health such as those with learning disabilities or LGBT people
- Indicated: targeting people at the highest risk of mental health problems and potentially showing early indications such as children whose parents have a serious mental health problem.
It is important that professionals who work with children are alert to emerging difficulties and are able to respond early and in addition are listening closely to concerns raised by parents and those raised by the child.
 Mental Health Foundation: Prevention Review: Landscape paper (2015)
Early Intervention and Diagnosis
Intervening early can reduce both the risk of the development of a disorder and the risk of persistence into adult life leading to improved outcomes and generating potential savings for services and society. In conduct disorders the potential savings from each case prevented through early intervention have been estimated at £150,000 for severe conduct disorders and £75,000 for moderate conduct disorders.
Despite the clear need for early intervention, evidence suggests that 60-70% of young people are not offered evidenced based interventions at the earliest opportunity.
 Friedli L, Parsonage M (2007) Mental health promotion: building an economic case. Belfast: Northern Ireland Association for Mental Health
Maternal Health and the Early Years
It is important that mothers receive the support they need to care for their children and that a strong bond develops between a baby and its parents during the first year of life. The Chief Medical Officer’s report Our Children Deserve Better, 2012 includes a number of intervention programmes as identified by the Evidence2Success project for the NICE Public Health Intervention Advisory Committee on the social and emotional wellbeing of vulnerable children aged 0–5 years.
Recommended cost effective interventions fell into the following categories:
- Pre-school curriculum interventions to enhance children’s readiness for school, in particular skills in language and literacy.
- Parenting group programmes to improve children’s behaviour.
- Parent and child therapy programmes to improve children’s relationships with their parents/carers.
- Home visiting programmes to improve children’s relationships with their parents/carers
- Intensive child and family support programmes to improve behaviour and children’s relationships with their parents/carers.
Several additional programmes were cited without adequate cost-effectiveness studies but with strong evidence of efficacy. These included:
- The detection and treatment of postnatal depression.
- Improving relationship quality in the first year of life (e.g. video feedback interactive programmes).
- Specific child maltreatment prevention programmes based on family therapy and social learning principles, which achieve increased maternal educational attainment and parent involvement in school as well as decreased family problems.
Parenting education is a key intervention for the promotion of mental health in children. The parent or caregiver/child relationship is vital to a child’s development and future psychological wellbeing. The Healthy Child Programme led by the health visiting service is an evidence based programme that includes information and guidance to support parenting as part of its universal component.
There are many evidence based targeted parenting programmes such as Triple P, Incredible Years  and Family Links. In an Australian trial the Triple P Programme was reported to demonstrate a 22% reduction in mental health problems in children and a 22% reduction in emotional distress in parents in less than three years.
The Family Nurse Partnership is a voluntary home visiting programme for first time young mothers and fathers, aged under 20 years at conception. It is underpinned by an internationally recognised robust evidence base, which shows it can improve health, social and educational outcomes in the short, medium and long term, while also providing cost benefits. A recent Randomised Control Trial here in the UK found that whilst the FNP programme appeared to improve early child development, at 24 months and may also help protect children from serious injury, abuse and neglect through early identification of safeguarding risks, FNP did not have an impact across the study’s four main short term outcomes – pre-natal tobacco use, birth weight, subsequent pregnancy by 24 months and A&E attendances and hospital admissions in first two years of life. A wide range of secondary outcomes assessed also didn’t show significant benefits for FNP at this stage.
Systematic reviews of interventions to prevent conduct disorder, anxiety and depression before adulthood have shown that programmes targeting at-risk children that involve families, using parent training or child social skills training are the most effective, with a reduced rate of relapse.
 Caestecker L, Killoran-Ross M (2010) Early years and public health: a case study from the Glasgow experience. In Goldie I (ed) Public Mental Health Today. A handbook (pp.121-134). Brighton, Pavilion Publishing/Mental Health Foundation.
 Saunders,M.,Ralph,A.,Thompson,R.,Sofrnoff,K,Gardiner,P Bidwell & Dwyer S (2005) Every Family: A Public Health approach to promoting children’s wellbeing. University of Queensland
 DH (2011) No Health Without Mental Health: Delivering better mental health outcomes for people of all ages. Department of Health.
School Based Programmes
Schools have an important role to play in enabling our young people to grow into functional adults; part of this is through promoting mental health and wellbeing.
Targeted approaches are required for children who are showing early signs of emotional and social difficulties. NICE recommends that schools should ensure teachers and practitioners are trained to identify and assess the early signs of anxiety, emotional distress and behavioural problems among primary schoolchildren. They should also be able to assess whether a specialist should be involved and make an appropriate request.
Effective school based programmes should be implemented consistently, over a long period of time, with sustained investment and should:
- Start early – the most effective programmes are those targeting the youngest children.
- Adopt a whole school approach where mental health work is integrated across a whole range of school activity, including the curriculum.
- Include explicit work on the development of mental health skills in students, staff and sometimes parents.
Table 7: Mental Health and Emotional Wellbeing Programmes for Children and Young People
|Interventions for antenatal & postnatal mental health||Evidence-based advice on the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth), and in women who are planning a pregnancy.
It offers evidence-based advice on the recognition, assessment, care and treatment of mental health problems in women during pregnancy and the postnatal period (up to 1 year after childbirth), and in women who are planning a pregnancy.
This guideline covers the identification, assessment and treatment of attachment difficulties in children and young people up to age 18 who are adopted from care, in special guardianship, looked after by local authorities in foster homes (including kinship foster care), residential units and other accommodation, or on the edge of care. It aims to address the many emotional and psychological needs of children and young people in these situations, including those resulting from maltreatment.
|Antenatal and postnatal mental health: clinical management and service guidance. NICE guidelines [CG192] Published date: December 2014
Antenatal and postnatal mental health: clinical management and service guidance
NICE guidelines [CG192] Published date: December 2014
Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care
NICE guidelines [NG26] Published date: November 2015
|Social and Emotional wellbeing in early years||The guidance is for all those responsible for planning and commissioning children’s services in local authorities (including education), the NHS and the community, voluntary and private sectors.
It also for: GPs, health visitors, midwives, psychologists and other health practitioners, social workers, teachers and those working in all early years settings (including childminders and those working in children’s centres and nurseries).
· Adopt a ‘life course perspective’
· Focus on social and emotional wellbeing as the foundation for the healthy development of vulnerable children and to offset the risks relating to disadvantage
· Aim to ensure universal, as well as more targeted, services provide them with additional support
· Should be used in conjunction with local child safeguarding policies.
|Social and emotional wellbeing: early years
NICE guidelines [PH40] Published date: October 2012
|Social and emotional wellbeing in primary education||NICE recommendations include:
• Local authorities should ensure primary schools provide an emotionally secure environment that prevents bullying and provides help and support for children (and their families) who may have problems.
• Schools should have a programme to help develop all children’s emotional and social wellbeing. It should be integrated it into all aspects of the curriculum and staff should be trained to deliver it effectively.
• Schools should also plan activities to help children develop social and emotional skills and wellbeing, and to help parents develop their parenting skills.
• Schools and local authorities should make sure teachers and other staff are trained to identify when children at school show signs of anxiety or social and emotional problems. They should be able to discuss the problems with parents and carers and develop a plan to deal with them, involving specialists where needed. Those at higher risk of these problems include looked after children, those in families where there is instability or conflict and those who have had a bereavement.
|Social and emotional wellbeing in primary education
NICE guidelines [PH12] Published date: March 2008
|Social and emotional wellbeing in secondary education||• Secondary education establishments should have access to the specialist skills, advice and support they require.
• Practitioners should have the knowledge, understanding and skills they need to develop young people’s social and emotional wellbeing.
• Secondary education establishments should provide a safe environment which nurtures and encourages young people’s sense of self-worth, reduces the threat of bullying and violence and promotes positive behaviour.
• Social and emotional skills education should be tailored to the developmental needs of young people.
|Social and emotional wellbeing in secondary education
NICE guidelines [PH20] Published date: September 2009
|Evidence based interventions for the long term management of self-harm||NICE Guidance for Health & Social Care professionals who come into contact with CYP aged between 8 and 17 years inclusive who self- harm.||Self-harm in over 8s: long-term management
NICE guidelines [CG133] Published date: November 2011
|Evidence based interventions for Eating Disorders in CYP||NICE recommends that most people with anorexia should be managed on an outpatient basis with psychological treatment by a team skilled in working with this disorder; for children and young people, family.
|Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders
NICE guidelines [CG9] Published date: January 2004
|Evidence base for CYP with ADHD||The Guidance covers
· Prerequisites of treatment and care for all people with ADHD
· Identification, pre-diagnostic intervention in the community and referral to secondary services
· Diagnosis of ADHD
· Post-diagnostic advice
· Treatment for children and young people
· Transition to adult services
· Treatment of adults with ADHD
· How to use drugs for the treatment of ADHD
|Attention deficit hyperactivity disorder: diagnosis and management
NICE guidelines [CG72] Published date: September 2008
|Evidence-based treatments for CYP with depression||There are effective treatments for depression in children and young people. Cognitive behavioural therapy for depression has been shown to be effective in both individual and group settings.
NICE draws on the evidence base and practice learning for CAMHS, with the following providing a ‘snapshot’ of some of the key recommendations of the NICE guidance:
it is suggested that the following may help – advice on complementary and alternative therapies; information about mentoring/spiritual
guidance and local peer support groups; guidance on sleep and relaxation;
information about local and national helplines, information about mental health and about local voluntary organisations.
|Depression in children and young people: identification and management
NICE guidelines [CG28] Published date: September 2005
|Antisocial behaviour and conduct disorders in children and young people: recognition, intervention and management||Recommendations include:
· General principles of care
· Selective prevention
· Identification and assessment
· Identifying effective treatment and care options
· Psychosocial interventions – treatment and indicated prevention
· Pharmacological interventions
· Organisation and delivery of care
Psychosocial therapies are used for the treatment for conduct disorders and are both clinically and cost-effective. Up to the age of 11 years, conduct disorders are best treated through the modification of parenting practices, the key factor being to improve positive parenting.
All effective treatments for conduct disorder involve the family, multisystemic therapy, brief strategic family therapy and functional family therapy appear effective for moderate-to-severe cases.
Three themes are common to all interventions recommended: a strong focus on working with parents and families, recognition of the importance of the wider social system in enabling effective interventions and a focus on preventing or reducing the escalation of existing problems. The guidelines cover a range of interventions including treatment, indicated prevention and selective prevention.
|Antisocial behaviour and conduct disorders in children and young people: recognition and management
NICE guidelines [CG158] Published date: March 2013
 NICE (2008) PH12 Promoting children’s social and emotional wellbeing in primary education. National Institute for Health and Clinical Excellence
Workplace Mental Wellbeing
NICE Public Health Guidance 22: Promoting mental wellbeing through productive healthy working conditions, 2009
Recommendations for employers are concerned with the adoption of an
organisation wide approach to promoting mental well-being, Employers should:
- Integrate the promotion of mental well-being into all policies and practices concerned with managing people, including those related to employment rights and working conditions.
- Create an awareness and understanding of mental well-being and reduce the potential for discrimination and stigma related to mental health problems.
- Ensure systems are in place for assessing and monitoring the mental well-being of employees so that areas for improvement can be identified and risks caused by work and working conditions addressed.
- If reasonably practical, provide employees with opportunities for flexible working according to their needs and aspirations in both their personal and working lives.
- Strengthen the role of line managers in promoting the mental well-being of employees through supportive leadership style and management practices.
Mental health of adults in contact with the criminal justice system. NICE Guidance 66
This guideline covers assessing, diagnosing and managing mental health problems in adults (aged 18 and over) who are in contact with the criminal justice system. It aims to improve mental health and wellbeing in this population by establishing principles for assessment and management, and promoting more coordinated care planning and service organisation across the criminal justice system.
Mental wellbeing in over 65s: occupational therapy and physical activity interventions. NICE Public Health Guidance 16
This guideline covers promoting mental wellbeing in people aged over 65. It focuses on practical support for everyday activities, based on occupational therapy principles and methods. This includes working with older people and their carers to agree what kind of support they need.
Older People Independence and mental wellbeing. NICE Guidance 32
This guideline covers interventions to maintain and improve the mental wellbeing and independence of people aged 65 or older and how to identify those most at risk of a decline.
The evidence suggests that a broad range of services are required to support mental wellbeing of children and adults to prevent mental health problems occurring. These should take into account risk and protective factors in a number of environments and across all age ranges. Our evidence based recommendations are as follows:
- Ensure that mental health is ‘everybody’s business’, to include the broader functions of the Local Authority, the NHS and key partners as commissioners and as employers
- Early (or earlier) interventions to change long term outcomes for people, including physical health, personal, social, environmental and economic wellbeing, regardless of age
- Focusing on the maintenance or recovery of a good quality of life throughout the life course
- Personalisation and personalised approaches for all commissioned services.
- Co-production, involving a changed relationship with people who are accessing support around their mental health
- Use knowledge, evidence and information to assure quality, productivity and outcomes
- Utilise a range of market management and procurement approaches to ensure service choice, diversity, quality, safety and effectiveness
- Shifting the balance of resources away from secondary NHS care to upstream community based support