A good start in life

Most mental illness has its origins in childhood. The most important modifiable risk factors for mental illness and the most important determinants of mental wellbeing are childhood ones. The most important opportunities for prevention of mental illness and promotion of mental health therefore lie in childhood, many of them in the context of the family.

The figures on mental illness in childhood are stark:

half of all mental disorder first emerges before the age of 14 years and three quarters by age 25 years (1)
up to 25% of children show signs of mental health problems (2) more than half of which track through into adulthood
10% of children have a clinically diagnosed mental disorder at any one point in childhood.(2) Only a minority of such children are in touch with services (2), (3)
the most common childhood mental disorder is conduct disorder with a prevalence of 5%. (2)

Key risk factors are modifiable

The most important modifiable risk factor for mental health problems in childhood, and thus in adult life in general, is parenting. The key way to reduce risk in very early childhood is to promote healthy parenting focusing on the quality of parent-infant/child relationships, parenting styles including behaviour management, and infant and child nutrition (including breast-feeding and healthy eating). Parental mental illness and parental lifestyle behaviours such as smoking, and drug and alcohol misuse are important risk factors for childhood mental health problems. (4)

Schools offer another important opportunity for promotion and prevention. School, school ethos, bullying and teacher wellbeing all have an influence on children’s current and future mental health. Mental health promotion programmes can modify these factors, and also mitigate mental health problems initiated from within the family. (5)

All the risk factors for mental illness also impact on cognitive development, leaving children doubly disadvantaged. Supporting children’s emotional and social development is the most effective way to promote cognitive development and thus to mitigate the effect of educational inequality throughout the lifecourse. (6)

Science of parenting and brain development

The scientific underpinning of mental health promotion in childhood has been investigated in several different disciplines and is now quite well understood. Studies show how interactions between young children and their parents or primary care-givers profoundly influence the development of the many parts of the brain, particularly those involving emotional and social development, speech and language and the child’s ability to manage life’s stresses.

Poverty and deprivation

Poverty and deprivation make parenting more difficult, but high quality parenting can protect against the effects of deprivation. (7) Abusive and neglectful parenting is associated statistically with poverty and deprivation, (8) but suboptimal parenting that is less damaging than abuse or neglect is distributed across the social spectrum. (9)

Parental mental illness and drug and alcohol misuse

The children most at risk of mental illness are those being raised in families where parents have a mental illness (10) or abuse drugs or alcohol. Standard parenting programmes may have limited impact where families are very dysfunctional. It is worthwhile improving parenting in such families and programmes are emerging which can do this. (11)

There are strong intergenerational links in mental illness, and genetic transmission is one of the non-modifiable risks. The expression of genetic risk is, however, influenced by the environment including parenting. (12) (13)

Interventions

Childhood programmes represent by far the largest group of evidence-based approaches to promote mental health. A wide range of programmes has been developed and evaluated, and a very large evidence base has accumulated over the course of the last 60 years. These cover universal, targeted and indicated approaches, and relate to interventions to support parenting and interventions to improve mental health in schools.

The majority of evidence-based parenting programmes address targeted or indicated populations. Some well-known parenting programmes combine parenting support with high quality day care or school-based interventions. These programmes can improve both children’s and parents’ mental health and wellbeing. The extent of improvement which can be made in each generation is modest but worthwhile.

Targeting, though attractive, can be inefficient because there is no reliable way to identify high risk groups, for example, parents with mental illness or parents who abuse drugs and alcohol. Current policy recommends universal underpinning and targeted provision for identifiable high risk groups like teenage parents, or high risk, socially disadvantaged areas.

Intervention research

Many different types of research are needed to tell whether interventions, programmes or approaches make a difference for whom, in what circumstances. Randomised controlled trials (RCT) are often difficult to carry out in health promoting settings and, whilst reducing some biases, may introduce others. Positive results are valuable, but may offer spuriously precise estimates of effect size, and negative results may not be able to distinguish between problems which ensue from trying to implement programmes in the context of an RCT and ineffective programmes.

Support for parenting and school mental health promotion features in much past and current public and child health policy. Provision varies throughout the UK and may be provided in health, education or third sector settings.

References

1) Kessler R, Berglund P, Demler O et al. Lifetime prevalence and age of onset distributions of DSM-VI disorders in the national comorbidity survey replication Arch. Gen. Psych. 2005;593-602

2) Green H, McGinnity A, Meltzer H, Ford T, Goodman, R. Mental health of children and young people in Great Britain, 2004 Palgrave Macmillan 2005

3) Sawyer MG, Arney FM, Baghurst PA et al. The mental health of young people in Australia: key findings from the child and adolescent component of the national survey of mental health and well-being. Australian and New Zealand Journal of Psychiatry; 35: 806–814

4) Göpfert M, Webster J, Seema MV, (eds). Parental psychiatric disorder: distressed parents and their families. Cambridge, CUP 2004

5) Weare K. Promoting mental, emotional, and social health: a whole school approach. Psychology Press, 2000

6) National Research Council Institute of Medicine. From neurons to neighbourhoods: the science of early childhood. National Academy Press, 2000

7) Lempers JD, Calri-Lempers D, Simons R. Economic hardship, parenting and distress. Child development 1989;60:25-39

8) Gingrich RD, Hudson JR. Child Abuse in a small city: social psychological and ecological correlates; Journal of Sociology & Social Welfare 376, 1981.

9) Waylen A, Stallard N, Stewart-Brown S. Parenting and social inequalities in health in mid-childhood: a longitudinal study. European Journal of Public Health 2008;18(3):300-305; doi:10.1093/eurpub/ckm131

10) Göpfert M, Webster J, Seema MV. Parental Psychiatric Disorder: distressed parents and their families. Cambridge University Press. 2004.

11) Dawe S and Harnett P. Parenting under Pressure.

12) Dodge KA, Rutter M. Gene-environment Interactions in developmental psychopathology. Guilford Press. 2011.

13 Kim-Cohen J, Caspi A, Taylor A, Williams B et al. MAOA, maltreatment, and gene–environment interaction predicting children's mental health: new evidence and a meta-analysis Molecular Psychiatry. (2006); 11, 903–913