Mental health prevention focusing on parenting
A healthy start is crucial for mental health and wellbeing throughout life, with parenting being the single most important factor. Whilst most children in Europe experience a level of mental health that enables them to grow, develop, learn, socialise and participate actively in working and family life, the evidence suggests that parenting support could further improve their mental wellbeing both in childhood and in adult life. At the same time the mental health of a significant proportion of children is significantly compromised by poor parenting. Up to one in five children experiences developmental, emotional or behavioural problems, and up to one in eight suffers from a mental disorder. The consequences of poor mental health in childhood reach into adulthood, increasing the likelihood of low educational achievement, reduced productivity, criminality and violence as well as adult mental disorder, unhealthy lifestyles and the risk of ill health. Poor mental health brings a huge economic and social burden to European societies.
Policies and practices to support parenting both in the general population and amongst those at greater risk have an important contribution to make to society beyond ensuing better mental health and wellbeing
The evidence for what works in this document is based on a detailed analysis of 51 systematic reviews published in the scientific literature that were in turn systematically identified.
The selected interventions are are based on a combination of both universal and targeted approaches, ranging from low cost universal to high cost targeted programmes for high risk groups and can be classified as:
Some very low cost practices for all parents
There are a number of very low cost practices which could be adopted by all parents resulting in better sensitivity to and understanding of their infants needs and thus make parenting easier. It is true, that there is not so much evidence to support these practices, but, because they have little cost and very low possibility of harm, they can be recommended. The practices are:
- increasing parents awareness of the infant in the antenatal period by promoting abdominal massage
- promoting skin to skin care by putting the naked infant on the mother's naked breast immediately following delivery
- encouraging kangaroo care - both mothers and fathers carrying their infants with them in purpose made carriers for much of the day
- media based parenting programmes
Some slightly higher cost practices for all parents
These practices can also be adopted by all parents resulting in better sensitivity to and understanding of their infants needs and thus make parenting, and particularly fathering, easier. The practices are:
- Health care providers helping parents recognise their infant's abilities and developmental milestones, for example, the infant's sensory and physical abilities, through developmental guidance.
- Health care providers helping parents reduce sleeping problems and crying and managing temperamentally difficult infants through anticipatory guidance.
- Health care providers training mothers or fathers to offer their infants massage on a regular basis.
One practice found not to work
One approach to intervention in the perinatal period shown not to be effective is psychological debriefing after birth. In fact, it might even do harm.
Practices that prevent and treat postnatal depression, although more costly to implement, target a group where the detrimental impact on infant and child mental wellbeing is well known.
Three different psychosocial approaches to the treatment of post natal depression are equally effective:
- cognitive behavioural approaches;
- interpersonal psychotherapy; and.
- non-directive counselling.
Preventive practices that focus on high risk groups are effective; these are delivered on a one to one basis and may be offered by a wide range of trained health care providers; they include a range of psychosocial approaches and usually offer a combination of practical and emotional support.
Universal approaches to the prevention of postnatal depression are not effective.
There is no evidence that screening using a brief questionnaire relating to mother's mental health is effective but this is still widely used in Europe.
There is no systematic review evidence as yet to support practices which aim to identify, prevent or treat antenatal depression.
A range of practices that target demographically and socially high risk groups have been studied; they include short term practices based on manuals and very long term, multi-component practices which can be tailored to families needs.
The effective practices are:
- Short (around six sessions) sensitivity focused practices which promote parent infant communication in high risk infants and clinical samples are safe and effective. It is more effective to target high risk infants than high risk parents. These practices offer interactional guidance; their focus is on enhancing parental observation skills and increasing positive interchanges and enjoyment. These interventions include video interaction feedback. The evidence suggests that it is more effective to start after the infant is 6 months old.
- Multi-component long term home visiting practices can be effective in improving parenting and parent and infant mental health outcomes as well as indicators of child abuse in high risk groups such as teenage parents. Nurses offer at least weekly visits starting in the antenatal period. Practices need to focus on the positive, taking an empowering approach, and enhancing positive mother-infant interaction and enjoyment; these are more effective than psychodynamic practices focusing on problems in the relationship and difficult past life histories. The quality of the relationship that the practitioner forms with the mother is key to success. Practices which include an ecological model, taking other risk factors and environments into account are more successful. Longer term studies have found positive outcomes, which were missed in shorter term studies.
Parenting practices based on manuals using cognitive behavioural approaches and relational approaches are effective in preventing behaviour problems, reducing the severity of behaviour problems and improving parenting.
Practices have been mostly studied with high risk groups and seem to be most effective in the 3-11 years age group, although there is evidence of effect in older and younger children. Some studies have shown persistent effects in long term follow up.
Practices are effective with parents from a range of minority ethnic groups.
Practices improve maternal psychosocial health and improve indicators of abusive parenting.
Media based parenting practices using the telephone or DVDs can be effective and effectiveness is enhanced by up to two hours of therapist contact time.
Practices with a curriculum or manual, those including positive parent child interaction, emotional and communication skills, use of time out and parental consistency and requiring parents to practice new skills are more effective.
Practices in which parents' needs are respected and they are offered strengths based non- judgemental support are effective. The facilitation of support and acceptance by other parents in the group is also key.
These are the most challenging groups to improve children's wellbeing and prevent mental ill-health. They have also been the most difficult to study, and, unfortunately, too many studies are of poor quality to be certain about the results.
However, the following can be concluded:
In families with documented physical abuse, intensive family support, multi-component multi-systemic approachesand cognitive behavioural based parenting practicesshow some promise.
Some families in which emotional abuse has occurred and those where anger management is a difficulty, respond to group based behavioural parent training with additional anger management techniques.
Non-abusing parents in families where sexual abuse has occurred can benefit from cognitive behavioural therapy as can their children.
Parent infant psychotherapy shows some promise with emotionally abusing families, but study quality is an issue with these practices
Practices with parents with drug problems suffer from high levels of drop out. Two practices showed promise: one, a multi-component practice targeting mood, views of self as a parent, drug use and parenting skills delivered on a one to one basis; and one an attachment based parenting education practice delivered in a group.
What are the economic consequences of poor childhood mental health?
The economic consequences of poor childhood mental health are profound and can last into adulthood. A number of studies in the EU and beyond that have followed groups of children over many years indicate that, untreated, poor mental health and behavioural problems can lead to increased contact with the criminal justice system, a greater risk of homelessness, personal relationship difficulties and reduced levels of employment, often with lower salaries when employed. Within childhood, there are also major costs for families, education, health and social services. Some of these costs might be avoidable with timely effective early actions, including low-cost parenting interventions.
Making the economic case for action
Significant gaps remain in what we know about the cost effectiveness of investing in measures to promote and protect child mental health: most studies to date have focused on the case for investing in pre-school educational interventions. There is an emerging evidence base suggesting that investment in parenting interventions can be highly cost effective; the costs of parenting interventions are modest in comparison to the potential avoidable lifetime costs of poor mental health that some children may experience. It is important to note however that the cost effectiveness of these programmes will depend on the extent to which parents are willing to participate. Greater levels of participation can further help improve their cost effectiveness.
Questions for Consideration by Policy Makers
Universal or targeted approaches
There is a wide-ranging debate about whether preventive practices should be offered to all parents, or should be targeted to parents at greatest need. Some practices show the greatest effect when they are directed at parents with the highest level of need and with the greatest capacity to benefit. However, there are several arguments in favour of universally provided practices. First, they can improve mental wellbeing at population level. Second, they are less stigmatising. Third, universal practices can address problems before they reach clinical levels, and are therefore more genuinely preventive than practices that become available only after problems have developed. Policies to optimise children's mental wellbeing through parenting and family interventions are likely to be most effective if they offer elements of both approaches.
- Policy makers, health care managers and health care providers should provide a mix of relatively low cost practices for all parents, and higher cost effective practices for higher risk groups.
- The lower cost practices for all parents include promoting parental abdominal massage during pregnancy, skin to skin care immediately following delivery, encouraging infant carrying through kangaroo care, guidance on infant development and managing common problems, and promoting infant massage.
- These low cost practices can be supported by ensuring the relevant care guidance and training for health care providers.
- Employers can also assist by offering similar guidance and support to their employees who are parents to be and new parents.
- The higher cost effective practices for higher risk groups include targeted practices for postnatal depression in high risk groups, short sensitivity focussed practices for high risk infants, multi-component long term home visiting practices for higher risk parents, a range of parenting practices for high risk children to prevent behavioural problems and parenting support in families with high risk of emotional or physical abuse.
- These higher cost practices for high risk groups can be supported by relevant clinical and care guidance for health care providers, adequate training for health care providers to deliver practices based on non-judgemental approaches, and adequate staff and financial resources to deliver such practices to those in need.