Children, Adolescents and Young People up to 24 years in educational and other relevant settings

1. Introduction : The importance of working with children, adolescents and young people

In recent years, mental health issues of children, adolescents and young people – particularly the prevention of mental health problems and the promotion of positive mental health – have been receiving considerable attention throughout European Union Member States. The European Commission published a report On the State of Young People’s Health in the European Union in March 2000. Aimed at policy makers, analysts and researchers in the EU Member States, it outlines the particular health risks among young people in the EU and their health and well being and includes a section on mental health.

Mental Health Europe, a non governmental organisation based in Brussels and committed to the promotion of positive mental health and the prevention of mental distress, between 1997 and 2001, carried out two Action Projects financed by the European Commission, in the framework of the EU Community Action Plan for Health Promotion, Information, Education and Training. The report “Mental Health Promotion for Children up to 6 Years” was completed in 1999 and “Mental Health Promotion of Adolescents and Young People” was completed in 2001. Reports of the content and outcome of these projects are published in Directory format and are available upon request .

When discussing the mental health status of children, adolescents and young people, it is important to take into consideration the fact that they do not by any means form a homogeneous group. They can be divided into the following subgroups : young children (1-6 years), children (7-12 years), pre-adolescents and adolescents (13-18 years), and young adults (18-24 years). All these different age groups deserve particular and distinctive attention, one of the main reasons being that childhood and adolescence are crucial stages in life. The incidence of many disorders, for instance depression, is known to increase from childhood to adolescence, and to continue to rise into adulthood . Mental health promotion of these age groups is therefore essential since the influences in the early stages of the life cycle will have an impact on the rates of disorder in later stages of the child and young person’s life. Depression is one of the most prevalent psychiatric disorders that occurs across the life span, and which affects 340 million people world-wide.

Depressive symptoms, particularly in adolescents and young people are seen by adults as being part of the mood swings that can occur with changes in the developmental stages of the life cycle. However, if these symptoms do not go away, and the problems are left untreated, they can have long-lasting negative effects in all aspects of the young people in their adult years. Since the pace of a young person’s life is fast, it is important to prevent problems and intervene before it is too late and before problems become overwhelming and unmanageable.

Depression commencing in adolescence, is a highly recurrent condition causing severe psychosocial impairment, and is a major public health problem. Depression in childhood and adolescence is associated with subsequent adjustment problems, underachievement in education and suicidal behaviour . In addition, depression in children and adolescents has long been associated with conduct or oppositional disorder, aggression, antisocial behaviour, anxiety, and substance abuse Rohde, Lewinsohn, et al. 1991 269 /id.

According to the epidemiological data available, the lifetime prevalence of major depression is about 4% in the age group 12-17 and 9% at age 18 . Although some studies have found depression to be twice as high in females as in males, it has been shown from a developmental perspective that among children, male depressives are twice as prevalent as females, the reverse of the sex ratio in adolescence. The latest findings suggest an increase in the prevalence of adolescent depression . Moreover, population surveys show that one third of people that have met criteria for major depression in their lifetime report that the first attack occurred before the age of 21 (Andrews, G. 2001) Child adversities have also been linked with the presence of depression later in life. For example, a recent case-control study in Boston indicated that women who had suffered from any abuse in their childhood or adolescence were 3.4 times more likely to suffer from major depression in adulthood . Other childhood hardships have also been linked to a later risk for depression during adulthood, such as separation from a parent or family turmoil Kessler, Davis, et al. 1997 393 /id . Children of depressed mothers are 50% at increased risk for depression (Downey et al., 1990) and children and adolescents who suffer from depression are at greater risk for recurrence of depression than are adults.

2. Objectives

Within the scope of the current large scale project, Mental Health Europe was responsible for the co-ordination of the sector “children, adolescents and young people up to 24 years in educational and other relevant settings”. National partners were selected from Member States of the European Union and the European Economic Area (EEA) countries and were responsible for the project work in their country.

From the outset, the objectives of the sector on children, adolescents and young people in educational and other relevant settings were identical to those of the other sectors of the project. On the one hand, these objectives were to gather relevant information concerning the impact of anxiety, depression and related disorders and the management of these problems with regard to promotion and prevention activities in the different EU Member States and the EEA countries. On the other hand, the project aimed at identifying and evaluating strategies, projects and models of best practice from the participating countries, in order to develop a common strategy for coping with the problems of anxiety, depression and related disorders. Such a strategy shall be evidence-based and for that reason there is recognition of the need to identify existing effective projects and policies that can provide a platform to develop an effective and efficient strategy.

3. Process and Methods : Identification and selection of mental health promotion projects across Europe

In order to identify and recruit national partners for this project, Mental Health Europe contacted its national member organisations, the European Network for Health Promoting Agencies (ENHPA), some of the National Members of the EC Health Promotion Committee and others to ask them to propose prospective partners.

As a result, a network of national partners was created in 12 of the EU Member States (Denmark, Ireland and Luxembourg did not participate ) and the EEA-countries Iceland and Norway. Represented in the network were partners from institutes, organisations and centres in the field of mental health with a particular interest in mental health promotion and prevention for children, adolescents and young people.

The task of the National Partners in each of their countries was to identify and to evaluate, projects and models of best practice in mental health promotion and the prevention of anxiety, depression and related disorders in the target group ofchildren, adolescents and young people up to 24 years and in various settings. National partners were encouraged to contact research institutes and universities in their country where project development, implementation and evaluation are undertaken. This exercise also had the beneficial aspect of putting the practice field in contact with different research groups in their countries and facilitating future collaboration in project design, evaluation and implementation.

Three experts were appointed with expertise in mental health promotion and prevention of mental illness, child and adolescent mental health promotion, and child and adolescent psychiatry. All three had also been involved in the previous project undertaken by Mental Health Europe in 2000-2001 « Mental Health Promotion of Adolescents and Young People ».

Their particular task in the current project was to participate in meetings of the network, to help with the development of the inclusion criteria and subsequently in the selection of best practices for the sector. They assisted also with the preparation of the final report, including the conclusions and recommendations derived from the research in the countries involved.

During the first meeting of the national partners, a set of key criteria was agreed that the projects to be collected would have to fulfil.

The probability of including a project being included in the final list to be recommended for wider use within Europe was related to its capability to fulfil as many as possible of the following criteria :

• The project was evaluated by using some kind of a control or comparison group. If this was not the case, then before and after evaluations may be acceptable .

• It was planned and designed by multi-professional teams, including both practitioners and researchers, and ideally including end users/sufferers in the design.

• It was delivered by multi-professional teams, and ideally had some involvement by end users and involvement of peers.

• It was applied on a larger scale and with larger numbers of people (i.e. at least local level, rather than just one site).

• It used several inter-related methods and approaches such as . education for professionals as well as treatment interventions and therapies.

• It was in place for some time (at least two years and ideally longer).

• It was fully reported in writing with full methodological details so that they could be judged properly.

• It was sustainable, did not require special resources, specially trained personnel, or a great deal of finance – the project could be built on existing capacity.

• It was based on a clear assessment of needs and ideally including the expressed needs of end users.

This list of criteria is not an exhaustive list.

Partners were asked to identify projects that aimed to promote mental health and prevent anxiety and depression in children, adolescents and young people. Projects included in the review were defined as :

 Projects that specifically would target and measure anxiety, depression and related disorders in children, adolescents and young people

 Projects that would work on wider mental health themes than just anxiety and depression, for example whole school health, prevention of bullying, maternal well being, but that would include measures of anxiety and depression in its outcomes ;

 Projects that would target known risk and resilience factors for mental health in individuals (for example self-esteem, self-confidence, ability to make decisions)

 Projects that would target known risk and resilience factors for larger groups, communities, regions or nations (for example poverty, poor levels of social capital)

To collect and systematise the information gathered from each of the projects, the partners were provided with two questionnaires (see questionnaire I in annex 1, and questionnaire 2 in annex 2). These questionnaires had been drafted before the first partner’s meeting and were adapted and modified for the sector of children, adolescents and young people according to the suggestions of the experts and national partners of the sector.

Questionnaire I focused on outlining the broad approaches and the prevalence and burden caused by anxiety disorders and depressive disorders. Questionnaire II aimed at collecting detailed information of the projects and practices in each country.

The national partners were given six months to identify, select and describe the projects from their country. The project Executive Committee and the experts evaluated the projects subsequently on the basis of a pre-determined system of evaluation and inclusion criteria as described in the next section.

4. Selected projects implemented across Europe

4.1. Results

The projects collected by the national partners of the sector “Children, adolescents and young people up to 24 years in educational and other relevant settings” ranged from relatively small-scale practical interventions through local and regional initiatives up to those at national and international levels. After carrying out a pre-selection in their country, the 14 countries involved submitted a total of 32 projects.

Responses to the Questionnaires varied greatly from country to country. Replies received from Austria, Italy and Germany were rather scant whereas Sweden, Norway, the Netherlands, Portugal and Iceland provided a number of very good projects. The poor responses would appear to be the result of the absence of any national mental health plan in these countries and in particular to the fact that mental health promotion and prevention strategies are still not deemed a priority for a number of member states.

Mental Health Europe’s experts held a meeting to analyse and evaluate the projects that had been selected by the national partners. Since the aim of the project was to develop an evidence-based strategy for mental health promotion and prevention to cope with anxiety, depression and related disorders in children, adolescents and young people, it was considered essential to identify and include as best practices only effective and evidence-based projects.

Among the 32 projects collected, a total of 15 projects were identified as well evaluated projects but since six of them had not yet been completed, it was decided to select as best practices the nine projects only that had been completed at the time of collection. This did not mean that the other projects were not effective, but at the time of reporting, many good and promising projects had not been able to provide sufficient documented evidence of effectiveness and/or sufficient information on the outcome of the project.

Of the 32 projects in total, five were focussed on the target group of children with psychiatric parents, five were about awareness-raising, ten projects were school based interventions, six dealt with anxiety, depression, and suicide, two were community interventions and four projects dealing with care, treatment and rehabilitation fell outside the scope of this project and were therefore not taken into consideration.

It was interesting to note that eighteen projects targeted anxiety and depression, seven were mental health promotion and prevention projects and eight were general health promotion and prevention projects.

A majority of the projects were school interventions, aiming to provide information about mental illness and to reduce stigma and prejudice. But there were also projects for babies of depressed mothers, group treatments in community mental health centres, projects working with juvenile offenders, and self-help groups.

Strategies which were used in the school setting and adopted a whole school approach encouraged young people to talk about their feelings, to get on better with peers, to manage anger, and reduce conflicts and bullying, to enhance resilience and educate teachers to support these initiatives, revealed themselves to be the most effective in reducing mental health problems, including anxiety and depression.

4.2. Selection of Best Practices

The nine projects in this category that were selected as best practices come from the Netherlands (2), Norway (1), Portugal (2), Sweden (2), and the United Kingdom (2).

These projects revealed that the settings, strategies and methods used to attain their aims were varied. Settings included community centres, primary health care settings, juvenile justice settings, but schools proved to be the preferred location for mental health promotion and prevention projects for children and adolescents in coping with anxiety and depression.

Projects in schools aimed mostly to raise awareness, to stimulate discussion and to improve the knowledge about mental illness among students and teachers. It is important that teachers are trained so that they recognise early symptoms of anxiety and depression. At the same time, schools should be linked with community services and school staff should be knowledgeable about the scope of services provided by community agencies.

Target groups often included the general population of children, adolescents and young people but also more specifically children of psychiatric parents, foster children, juvenile offenders, teachers, parents, etc. These target groups were specifically defined in relation to those youngsters who are most at risk or most likely to suffer from depression.

One striking feature of the projects that were received was the fact that most of them target adolescents and young people between 14 and 24 years of age. There were however projects for pregnant mothers and their babies but children in the age range from 2 years to 7 years seem to be an age group in which projects in relation to mental health prevention or promotion interventions against child abuse, and especially in early school settings have yet to be developed.

The following chart gives an overview of the selected best practices. A more detailed description with contact details can be found in the annex.

All the other projects that were received are also described in the annex.

COUNTRY : Netherlands

PROJECT : Coping with Depression Course

DESCRIPTION : Group treatment developed to reduce depressive symptoms and to prevent the onset of depressive disorder.

COUNTRY :Netherlands

PROJECT : Dealing with Moods

DESCRIPTION : A preventive intervention project in schools. Elevated levels of depressive symptoms in adolescence are associated with a host of behavioural problems and can be a precursor of depressive disorders. This intervention was designed to reduce elevated levels of depressive symptoms and enhance cognitive, social & behavioural competence as protective factors in the prevention of depressive disorder

COUNTRY :Norway

PROJECT :Second Step

DESCRIPTION :A universal prevention project designed to reduce aggression and promote social competence. The programme is designed to develop skills that are central to children’s healthy social and emotional development : a) empathy, b) impulse control and problem solving, and c) anger management. It is a practical tool to use for teachers to create a better environment in the classroom.

COUNTRY :Portugal

PROJECT :

1 Psychoprophylaxis and Pregnancy. A Psychosocial intervention among pregnant women with high anxiety

2 Working with juvenile offenders and adolescents at risk in the community

DESCRIPTION :

1 A clinical research project implemented in local primary care units. The key messages of this project are that it is possible to say that there is a psychological risk during pregnancy with implications on the obstetrical outcome and in the mothers’ emotional state after birth (only women with a low biological risk were taken into consideration). The psycho-prophylactic intervention in pregnant women with high levels of anxiety (risk group) is able to bring restricted but significant changes, a lower frequency of dystocias and an increased number of women in the social-support network of the mothers near to the birth.

2 Probation officers working with adolescents with anti-social behaviour in the community. It is a joint project between a university and the Ministry of Justice and included an intervention with youngsters and training for probation officers. It was fully evaluated in 2002. The important aspect of this project is to have juvenile offenders participate and feel empowered changing their own lives and feeling good about it.

COUNTRY :Sweden

PROJECT :

1 Love is the best kick

2 Life Skills

DESCRIPTION :

1 This is a Video film aiming to increase the self-concept of young people about existential problems, identity, relationships, love, etc. It is used -together with a teacher’s guide and an information booklet for young people -to enable classroom discussions about such difficult existential issues as suicidal ideas and acts among teenagers. Looking at the film and discussing it has shown to enhance young people’s understanding of themselves and their suicidal peers. One of the most important results of this project is that their suicidal thoughts decreased.

2 A time-effective method for schools to prevent mental and psychosocial ill-health, loneliness and bullying, and to give hope that personal problems can be solved, supply help and information on how to seek help at an early stage. Preliminary results of an evaluation show that the number of self-reported suicide-attempts decreases in schools where the method is used compared with a control group.

COUNTRY :United Kingdom

PROJECT :

1 The development of adolescent pupil’s knowledge about and attitudes towards mental health difficulties

2 The Foster Carers’ Training Project

DESCRIPTION :

1 A project teaching pupils about stress, depression, suicide, eating disorders, bullying, and learning disorders.

2 A randomised controlled trial of a training project for foster carers, which aimed to improve the emotional and behavioural functioning of looked-after children. The three-day training was well received by foster carers and produced measurable, though non-significant reductions in symptoms of depression, anxiety, over-activity, conduct problems and attachment disorder in the children.

4.3. The need to take a whole school/ whole community approach

While it may be helpful to introduce specific projects which attempt to prevent anxiety and depression in children and young people, it is equally important to work within an overall ‘settings’ approach to ‘health promotion’, which takes account of environments rather than individuals as both the focus for concern as well as a focus for positive well being, and not just on problems and deficits. This does not just involve schools : using a range of settings, including school, home and community rather than just one setting has been shown to be much more likely to make long term changes to students’ mental health (Catalano et al, 2002). In practice the arena in which the setting approach has been best developed is schools. The European Network of Health Promoting Schools, which covers all the countries of Europe, has been one of the most successful globally in promoting a settings whole approach to health, including mental and emotional well being, and it is advisable that initiatives work within its principles, and where possible the networks that have been established.

There have been several recent large scale systematic reviews of the research evidence which have concluded unequivocally that controlled trials have shown that the whole school approach is more effective than targeting alone when attempting to tackle mental health in schools (Lister Sharpe et al, 2000 ; Wells et al, 2003 ; Catalano, 2002). The whole school approach does not just focus on individuals with problems but on the positive well being of all the people who work and learn there, staff as well as students, and on the totality of the school setting, which includes its ethos, relationships, communication, management, physical environment, curriculum, special needs procedures and responses, relationships with parents and the surrounding community. (Weare, 2000). A whole school approach emphasises the need to develop a long term, sustainable, and co-ordinated approach across all parts of the school to all health issues, including mental health.

This does not mean that those with emotional difficulties should not be targeted, it means that any targeting will be more effective within a whole school approach. There are a range of reasons why this would be the case. Emotional problems, including anxiety and depression are extremely widespread, and if an arbitrary population is targeted, the very many people who suffer from a problem to some extent will be ignored. The same basic processes that help those with emotional difficulties have been shown to promote the emotional well being of all -including teachers as well as students. The key processes include : beginning interventions early ; promoting self esteem ; giving personal support, guidance and counselling ; building warm relationships ; setting clear rules and boundaries ; involving people in the process ; encouraging anticipation and autonomy ; involving peers and parents in the process, creating a positive school climate, and taking a long term, developmental approach (McMillan, 1992 ; Cohen, 1993 ; Rutter et al, 1998). If there is an overall social climate that supports emotional well being it is more likely that fewer children will have problems in the first place, so a whole school approach has a preventive function. Those with problems will be spotted early and staff will be more confident of their assessment because they have a clearer yardstick of normality. It is less stigmatising to work with everyone, which means that those with problems are more likely to use the services offered and feel positive about them than if they feel they are being singled out. The principle of ‘herd immunity’ means that the more people in a community, such as a school, who are emotionally and socially competent, the easier it will be to help those with more acute problems. The critical mass of ordinary people has to the capacity to help those with problems (Stewart-Brown 2000). Those who are given extra help will be able to return to mainstream school more easily, as the way they are dealt with in terms of special help is then congruent with the school to which they return.

4.4. Involving young people in the process

One criterion for inclusion of projects was that they involve end users, in this case mainly young people themselves, in the process. The principles of empowerment and user involvement are generally recognised across the policies of the European Union as an important contribution to the creation of a democratic society, and are basic to current European models of health promotion (WHO, 1986), health promotion evaluation (WHO, 1999). Compared with adult groups, young people are not often consulted about mental health matters, often being seen as too immature or too unreliable to know what is in their own best interests. However, there have been some interesting efforts to ascertain the views of young people about mental health and to build them into recommendations for action (Health Education Authority 1998 ; Harden et al, 2001). Also, to include a consideration of these views in developing indicators and instruments to measure aspects of mental health (Harter, 1993 ; Banks et al, 2001). These efforts have shown that young people are capable of making a well informed and considered contribution. It is therefore important to build on this work, and ensure that the voices and opinions of young people themselves shape significantly work that is intended to promote their mental health.

5. Recommendations

The analysis of all the projects from the sector for children, adolescents and young people to promote mental health and prevent anxiety and depression has led to a number of conclusions and recommendations for the Policy Report.

(1) Based on the results from Questionnaire I, it has become clear that many countries in the European Union still lack clearly defined mental health policies or do not have a national mental health plan. Those countries which do have an approved and sound mental health plan have produced a notably higher number of projects on the topic of the promotion of mental health and the prevention of mental illness, including anxiety and depression, of children, adolescents and young people. It is therefore of utmost importance to develop mental health policies in all Member States that focus on children, adolescents and young people and which address their needs. Governments should create strong and supportive infrastructures to promote and protect mental well being, collaborate internationally on enhanced anxiety and depression prevention research, disseminate the available knowledge of effective programmes widely, and create a properly resourced policy platform on mental health. There is a need to raise awareness of the importance of mental health issues at all levels.

(2) The end users need to be at the heart of the process. In order to meet this the planning, development and implementation of a mental health promotion project needs to include the genuine participation of children, and young people themselves from the concept stage through the implementation to the evaluation. Young people need to be not only consulted but have genuine power, influence and decision making over policy and practice. Parents likewise need to be similarly involved.

(3) Disadvantaged groups of children and young people have been shown to be at high risk for anxiety and depression. Countries should be encouraged to address social risk factors such as inequality, stigma, marginalisation, social exclusion and poverty and disadvantage with a special focus on children and adolescents.

(4) There is a need to take a positive overall focus, which starts from the strengths young people and their families have within themselves and to seek examples of positive mental health and well being .

(5) Holistic approaches need to be used that focus on the whole context in which young people find themselves both as the seat of understanding the causes of problems and as the site for solutions, in a co-ordinated and planned way. This needs to include the whole community with its health, leisure and educational resources, the full range of services available to help young people. A ‘ whole-school approach’ is essential, which involves teachers, pupils and parents in co-ordinated efforts to promote mental, emotional and social health across the whole school setting and for the whole population of the school, including teachers and also in co-operation with the surrounding community.

(6) Within this overall holistic approach targets include individual young people, groups of young people, and families, at particular risk of anxiety and depression and related disorders. These might include, for example young people whose parents suffer from mental illness and or enduring physical illness, those who have experienced particularly stressful life events, or are suffering from post traumatic stress.

7) It is also important not to treat this age group as a homogeneous group but to use a differentiated approach. Each stage in childhood and adolescence will require different methods and approaches towards promotion and prevention actions, and requires sensitivity to the differing needs of the genders, and to the different cultural and social groups.

(8) At an early stage of childhood, it is essential to support good parenthood and facilitate strong parent/child relationship development. Any intervention that aims to improve effectively the mental health of children and prevent anxiety and depression will have to address the quality of parenting that the children receive and also the quality of their family relationships.

(9) Close attention needs to be paid to the needs of children who have parents who are suffering from mental health disorders and problems, including encouraging targeted prevention programmes for this group.

(10) Within the overall community approach, well-supervised, safe play and leisure facilities for children, adolescents and young people should be provided throughout their formative years.

(11) Attempts need to be made to address the problems young people have within school wherever possible, with non-stigmatising, non-medicalised, interventions. Multiple and different outcomes such as anxiety, depression, substance abuse, suicide and attempted suicide should be addressed simultaneously.

(12) Particular efforts need to be made to support young people and their families through times of transition, as these can be a period of particular anxiety and stress. These include for example the move from home to school, from one school to another, and from school to work or higher education.

(13) More needs to be done to promote the mental health of carers : those who parent, educate, treat and work with young people in various ways.

(14) Particular initiatives are necessary to tackle bullying and violence in schools, home and community.

(15) An effort is needed to tackle the under achievement of many children throughout the European Community, without putting children under undue pressure, as under achievement has been linked with anxiety and depression.

(16) A special focus is required to tackle the pervasive problem of stigma and discrimination that surround mental health problems.

(17) There is a need to encourage more training and more multi-professional networking on mental health issues.

(18) Whenever possible new and existing initiatives should use and build on the evidence base from controlled, or pre and post evaluation studies, in order to develop appropriate strategies, approaches and programmes where the evidence base and development work should be based on a substantial and well founded body of theory. Far more priority should be given to evaluation of new and existing projects, with a great deal more resource devoted to it, and the creation of more effective partnerships between practitioners and the research centres which have the expertise in this area.

RECOMMENDATION

1. BASED ON THE RESULTS FROM QUESTIONNAIRE I, IT HAS BECOME CLEAR THAT MANY COUNTRIES IN THE EUROPEAN UNION STILL LACK CLEARLY DEFINED MENTAL HEALTH POLICIES OR SIMPLY DO NOT HAVE A NATIONAL MENTAL HEALTH PLAN. THOSE COUNTRIES WHO DO HAVE AN APPROVED AND SOUND MENTAL HEALTH PLAN HAVE PRODUCED A NOTABLY HIGHER NUMBER OF PROJECTS ON THE TOPIC OF THE PROMOTION OF MENTAL HEALTH AND THE PREVENTION OF MENTAL ILLNESS, INCLUDING ANXIETY AND DEPRESSION, OF CHILDREN, ADOLESCENTS AND YOUNG PEOPLE. IT IS THEREFORE OF UTMOST IMPORTANCE TO DEVELOP MENTAL HEALTH POLICIES IN ALL MEMBER STATES, THAT FOCUS SPECIFICALLY ON CHILDREN, ADOLESCENTS AND YOUNG PEOPLE AND TO ADDRESS THEIR NEEDS. GOVERNMENTS SHOULD CREATE STRONG AND SUPPORTIVE MENTAL WELL BEING INFRASTRUCTURES, COLLABORATE INTERNATIONALLY ON ENHANCED ANXIETY AND DEPRESSION RESEARCH, DISSEMINATE THE AVAILABLE KNOWLEDGE OF EFFECTIVE PROGRAMMES WIDELY, AND CREATE A PROPERLY RESOURCED POLICY PLATFORM ON MENTAL HEALTH. THERE IS A NEED TO RAISE AWARENESS OF THE IMPORTANCE OF MENTAL HEALTH ISSUES AT ALL LEVELS.

EXAMPLES  Dealing with Moods (Netherlands) : This project is not part of a governmental mental health policy but just a private project. It would be very helpful to have a national Depression prevention programme or more generally a mental health promoting policy.

 Second Step (Norway) : Norway will have a clearly defined mental health plan for children and young people, which will enter into force in autumn 2003. In Norway’s latest report to the UN regarding Children’s rights, young people were asked about what it was like to grow up in Norway. The report is called “Life under 18” (“Livet under 18”).

 Life Skills (Sweden) : Sweden is one of the countries that lack a clearly defined mental health plan. Evaluating suicide prevention projects is a way to endorse the government’s interest in this issue. This is one of the goals of the National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP).

 Love is the Best Kick (Sweden) : The government in Sweden has decided that it is important to translate the WHO programme “Preventing Suicide : a resource for teachers and other school staff”. This was done at the National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP) in a more extensive form.

 The Foster Carers’ Training Project (Scotland) : Scotland has recently produced the Scottish Needs Assessment Process Report on child and adolescent mental health which can be downloaded from the Public Health Institute of Scotland web site from www.phis.org.uk. This found that children’s mental health can be influenced at many levels of society and that this influence can be improved by good collaborative working between different agencies e.g. consultation to other professional groups can be an effective and efficient way of child and adolescent psychiatrists influencing children’s mental health in a much broader way. The Foster Carers’ Training Project (FCTP) fits in with this work in that it sees foster carers as the agents of therapeutic change for the children they look after, but also recognises that a consultative type of training can help carers achieve this.

1. THE END USERS NEED TO BE AT THE HEART OF THE PROCESS. IN ORDER TO MEET THESE NEEDS, THE PLANNING AND THE DEVELOPMENT AND IMPLE MENTATION OF A MENTAL HEALTH PROMOTION PROJECT NEEDS TO INCLUDE THE GENUINE PARTICIPATION OF CHILDREN, AND YOUNG PEOPLE THEMSELVES FROM THE CONCEPT STAGE THROUGH THE IMPLEMENTATION TO THE EVALUATION. YOUNG PEOPLE NEED TO BE NOT ONLY CONSULTED BUT HAVE GENUINE POWER, INFLUENCE AND DECISION MAKING OVER POLICY AND PRACTICE. LIKEWISE PARENTS NEED TO BE SIMILARLY INVOLVED.

EXAMPLES  Dealing with Moods (Netherlands) : The end users are involved in the process, they tested pilot versions of the project.

 Second Step (Norway) : The basis of this project consists of everyday topics and situations that are well known to children and young people. The teachers using this intervention have to make changes and adaptations to adapt it to their group of students. The implementation of the project involves the participants and the children, as it is their ideas and solutions that will be tried out in real life situations. The project serves as a frame but the students make the picture inside. The involvement of parents is also an important point, as social skills are learned in situations other than in the classroom, and as parents are important role models for their children.

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : The intervention with the adolescents included – besides a personal and social promotion programme – a group conversation at every session. Adolescents were required to identify their personal and social needs, and were challenged to propose ways to cope with those needs. Although the methodology had been decided beforehand, the specific topics covered depended very much on the results of these conversations, and adolescents were able to choose topics they wanted to discuss.

 Life Skills (Sweden) : The project was developed in co-operation with users.

 Love is the Best Kick (Sweden) : Many courses were organised for teachers, which gave opportunity to discuss how to use the intervention in schools and also how to change it to make it suitable for every special school and their pupils.

 The Foster Carers’ Training Project (Scotland) : Foster Carers had a key role to play in the design of the randomised controlled trial, by taking part in a qualitative focus group prior to the start of the main study. Children also had a role in helping to refine the questionnaires used as outcome measures.

2. DISADVANTAGED GROUPS HAVE BEEN SHOWN TO BE AT HIGH RISK FOR ANXIETY AND DEPRESSION. COUNTRIES SHOULD BE ENCOURAGED TO ADDRESS SOCIAL RISK FACTORS SUCH AS INEQUALITY, STIGMA, MARGINALISATION, SOCIAL EXCLUSION AND POVERTY AND DISADVANTAGE WITH A SPECIAL FOCUS ON CHILDREN AND ADOLESCENTS.

EXAMPLES  Dealing with Moods (Netherlands) : Several institutes have pointed out the relationship between social factors and mental ill health. There is still no national policy aimed at reducing ill health and unfavourable social factors.

 Second Step (Norway) : This project is targets the whole group of students. Positive feedback is one important tool for the teachers and parents to use. Empathy is also an important part of the project, and teachers report that it becomes easier for the well functioning students to accept those with problems.

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : This project is a good example of addressing disadvantaged groups. Adolescents that came from “elsewhere” (e.g. migrants), adolescents with a chronic disease, adolescents from families of unemployed, arrested criminal or unskilled workers with minimum national wage showed increased risk for depression and anxiety, conduct disorders and addiction. Also, taking into consideration the aspects of poverty, social exclusion and school distance, the majority of adolescents that were juvenile offenders had an African background, which was seen as a matter of lack of opportunities and sense of belonging.

 The Foster Carers’ Training Project (Scotland) : The project had a special focus on fostered children – among the most disadvantaged in society.

3. THERE IS A NEED TO TAKE A POSITIVE OVERALL FOCUS, WHICH STARTS FROM THE STRENGTHS YOUNG PEOPLE AND THEIR FAMILIES HAVE WITHIN THEMSELVES AND TO SEEK EXAMPLES OF POSITIVE MENTAL HEALTH AND WELL BEING.

EXAMPLES  Dealing with Moods (Netherlands) : It is one of the objectives of this project to strengthen cognitive and social competence as protective factors.

 Second Step (Norway) : The aim of this project is to focus on the positive choices one can make. Positive feedback from parents is important. The children need to see that positive behaviour gives them attention, as the attention from adults is one thing that children and young people in Norway rate as very important in their lives.

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : Some of the adolescents in this project were really good at solving problems and “highly resilient”. Work is being carried out taking these characteristics into consideration while trying to help them accept a more pro-social behaviour and cope with their life problems without alcohol, drugs and violence. One hour weekly was used to meet some of the parents and talk to them. The families are often not traditional and some have been arrested for crime themselves.

 Life Skills (Sweden) + Love is the Best Kick (Sweden) : This is the basic idea of the projects together with the holistic approach (5) as it is not focusing on problems and especially not suicidal problems. Within each topic in the project, the pupils formulate their own needs and what they should do to meet these needs.

 The Foster Carers’ Training Project (Scotland) : The project collects information from foster carers, teachers and from children themselves in an attempt to get a holistic view of the child.

EXAMPLES

4. HOLISTIC APPROACHES NEED TO BE USED THAT FOCUS ON THE WHOLE CONTEXT IN WHICH YOUNG PEOPLE FIND THEMSELVES AS BOTH THE SEAT OF UNDERSTANDING THE CAUSES OF PROBLEMS AND AS SITE FOR SOLUTIONS, IN A CO-ORDINATED AND PLANNED WAY. THIS NEEDS TO INCLUDE THE WHOLE COMMUNITY WITH ITS HEALTH, LEISURE AND EDUCATIONAL RESOURCES, THE FULL RANGE OF SERVICES AVAILABLE TO HELP YOUNG PEOPLE. A “WHOLE-SCHOOL APPROACH” IS ESSENTIAL, WHICH INVOLVES TEACHERS, PUPILS AND PARENTS IN CO-ORDINATED EFFORTS TO PROMOTE MENTAL, EMOTIONAL AND SOCIAL HEALTH ACROSS THE WHOLE SCHOOL SETTING AND FOR THE WHOLE POPULATION OF THE SCHOOL, INCLUDING TEACHERS AND ALSO IN CO-OPERATION WITH THE SURROUNDING COMMUNITY.  Dealing with Moods (Netherlands) : This project is only focussing on students. A more comprehensive approach could indeed be desirable.

 Step by Step (Norway) : This project uses a holistic approach.. The National Health Association in Norway works with a holistic approach to mental and physical health. They advise the schools and pre-schools using the “Second Step” project to have a plan for a whole-school implementation. The community perspective is very important.

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : While working with the adolescents, their families and their probation officers, the people responsible for the project aimed to help families cope with these adolescents, and acted as collaborators , including peers in this pro-social approach, so that adolescents can help each other to cope with life challenges instead of encouraging each other to engage in anti-social behaviour. Pro-social behaviour needs to be encouraged and perceived as a “social gain”. This intervention was explained to schools so that these adolescents would not be excluded (this was only successful in some of the schools). This intervention was also explained in the community, namely to job providers, so that these adolescents can get professional training and a job.

 Life Skills (Sweden) + Love is the Best Kick (Sweden) : Both projects use a holistic approach.

5. WITHIN THIS OVERALL HOLISTIC APPROACH TARGETS INCLUDE INDIVIDUAL YOUNG PEOPLE, GROUPS OF YOUNG PEOPLE, AND FAMILIES, AT PARTICULAR RISK OF ANXIETY AND DEPRESSION AND RELATED DISORDERS. THESE MIGHT INCLUDE, FOR EXAMPLE YOUNG PEOPLE WHOSE PARENTS SUFFER FROM MENTAL ILLNESS AND/OR ENDURING PHYSICAL ILLNESS, WHO HAVE EXPERIENCED PARTICULARLY STRESSFUL LIFE EVENTS, OR ARE SUFFERING FROM POST-TRAUMATIC STRESS.

EXAMPLES  Life Skills (Sweden) : Working with the Life Skills Programme gives the school nurse and the school counsellors information on the individual needs of the pupils. It is also a way to let the pupils become more acquainted with the school nurse and the school counsellor and less reluctant to seek help.

 The Foster Carers’ Training Project (Scotland) : Fostered children are such a group.

6. IT IS ALSO IMPORTANT NOT TO TREAT THIS AGE GROUP AS A HOMOGENEOUS GROUP BUT TO USE A DIFFERENTIATED APPROACH. EACH STAGE IN CHILDHOOD AND ADOLESCENCE WILL REQUIRE DIFFERENT METHODS AND APPROACHES TOWARDS PROMOTION AND PREVENTION ACTIONS, AND REQUIRES SENSITIVITY TO THE DIFFERING NEEDS OF THE GENDERS, AND THE DIFFERENT CULTURAL AND SOCIAL GROUPS.

EXAMPLES  Second Step (Norway) : This project focuses on children in pre-school (age 1-6) and schools (grades 1-7). The lessons are made to fit the different age groups. The problems that the young children talk about are simpler and less complex than the problems presented by the older children.

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : Depression, anxiety, conduct disorders and addiction tend to increase with age between 11 and 16 years, they tend to be related to different features with gender, with girls more prone to internalise and girls more prone to externalise. Co-morbidity is usually high. In this project, the focus was on boys from 14-16 years.

 Love is the Best Kick (Sweden) : By being in individual contact with children and adolescents after seeing the video, it is possible to be more aware of their specific needs, which is a reality for teachers and other school staff with students coming from different countries and different cultural backgrounds.

7. AT AN EARLY STAGE OF CHILDHOOD, IT IS ESSENTIAL TO SUPPORT GOOD PARENTHOOD AND FACILITATE STRONG PARENT/CHILD RELATIONSHIP DEVELOPMENT. ANY INTERVENTION THAT AIMS TO IMPROVE EFFECTIVELY THE MENTAL HEALTH OF CHILDREN AND PREVENT ANXIETY AND DEPRESSION WILL HAVE TO ADDRESS THE QUALITY OF PARENTING THAT THE CHILDREN RECEIVE AND ALSO THE QUALITY OF THEIR FAMILY RELATIONSHIPS.

EXAMPLES  Second Step (Norway) : The question that adults teaching this project have to be able to discuss with the parents is “why is social and emotional learning important ?” Information has been put together for the parents, and pre-schools and schools are informed that a successful implementation also involves parents.

 Psychosocial intervention with pregnant anxious women (Portugal) : This is a good example of a project supporting good parenthood.

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : The target group consists of adolescents with highly non traditional families. A broad preventive parenting programme would be most welcome though.

 The Foster Carers’ Training Project (Scotland) : Training of foster carers may be a key way of helping fostered children find the secure base they need to develop mental health in later life.

8. CLOSE ATTENTION NEEDS TO BE PAID TO THE NEEDS OF CHILDREN WHO HAVE PARENTS WHO ARE SUFFERING FROM MENTAL HEALTH DISORDERS AND PROBLEMS, INCLUDING ENCOURAGING TARGETED PREVENTION PROGRAMMES FOR THIS GROUP

EXAMPLES  Working with juvenile offenders and adolescents at risk in the community (Portugal) : Most of the adolescents in this project come from dysfunctional families (poverty, social exclusion- migrant background, alcohol abuse, violence, criminality, etc.). The way we address this fact with adolescents is capacity building ( resilience, problem solving, priority setting, building positive and realistic expectation towards future….)

 The Foster Carers’ Training Project (Scotland) : Although this project was not specifically targeted at children whose parents have mental illness, 52% of mothers of the looked after (fostered) children in the study had mental illness or learning disability, so targeting looked after children is one way of targeting this group.

9. WITHIN THE OVERALL COMMUNITY APPROACH, WELL-SUPERVISED, SAFE PLAY AND LEISURE FACILITIES FOR CHILDREN, ADOLESCENTS AND YOUNG PEOPLE SHOULD BE PROVIDED THROUGHOUT THEIR FORMATIVE YEARS.

EXAMPLES  Working with juvenile offenders and adolescents at risk in the community (Portugal) : The adolescents targeted by this project usually share the following characteristics : poverty, migration condition, living in “bad areas”, lack of schooling and education, lack of leisure facilities and a lack of dreams while being adolescent.

10. ATTEMPTS HAVE TO BE MADE TO ADDRESS THE PROBLEMS YOUNG PEOPLE HAVE WITHIN SCHOOL WHEREVER POSSIBLE, WITH NON-STIGMATISING, NON-MEDICALISED INTERVENTIONS. DIFFERENT MULTIPLE OUTCOMES SHOULD BE ADDRESSED SIMULTANEOUSLY (ANXIETY, DEPRESSION, SUBSTANCE ABUSE, SUICIDE.

EXAMPLES  Dealing with Moods (Norway) : The project is non stigmatising and simultaneously addresses depression.

 Second Step (Norway) : This project helps the children to learn how to solve problems. It helps the pupil understand the problem by defining it and makes him or her realise that there is always more than one solution.

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : In Portugal’s nation-wide programme, schools were mostly used as the programme setting. When schools were collaborative, results were much higher and the implementation easier. If a broad school-based action preventing mental health problems was possible, these problems could be prevented instead of having to be dealt with. This could include areas, such as anxiety, depression, conduct problems, addiction, suicide, problems of body image, sexual education.

 Life Skills (Sweden) + Love is the Best Kick (Sweden) : The Life Skills Project addresses bullying, the working environment, substance abuse, depression and suicide and one of the aims is to promote a help-seeking behaviour. When interventions are discussed, social and psychological interventions are referred to as well as medical interventions.

11. PARTICULAR EFFORTS NEED TO BE MADE TO SUPPORT YOUNG PEOPLE AND THEIR FAMILIES THROUGH TIMES OF TRANSITION, AS THEY CAN BE A PERIOD OF PARTICULAR ANXIETY AND STRESS. THESE INCLUDE THE MOVE FROM HOME TO SCHOOL, FROM ONE SCHOOL TO ANOTHER, AND FROM SCHOOL TO WORK OR HIGHER EDUCATION.

EXAMPLES  Second Step (Norway) : Anger is an important part of people’s lives but what is important is to know how to deal with anger. In this project, children learn how to recognise their own anger, how to calm down, and try to find positive ways to behave.

12. WE NEED TO DO MORE TO PROMOTE THE MENTAL HEALTH OF CARERS : THOSE WHO PARENT, EDUCATE, TREAT AND WORK WITH YOUNGER PEOPLE IN VARIOUS WAYS. EXAMPLES

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : Working with adolescents who have mental health problems requires a stable mental health from professionals. This project also tries to define the profile of the professionals who can best cope with this challenge.

13. PARTICULAR INITIATIVES ARE NECESSARY TO TACKLE BULLYING AND VIOLENCE IN SCHOOLS, HOME AND COMMUNITY.

EXAMPLES  Second Step (Norway) : The main idea of this project is the prevention of violence. The three parts of the project – empathy, problem-solving and anger management – are three important ways on how to prevent violence and bullying.

 Love is the Best Kick (Sweden) : In the school legislation in Sweden, you are supposed to have a special programme for tackling bullying and violence and this subject is also part of the programme connected to the video film. There is a special manual for adolescents to help them to start a discussion about different aspects of what can happen to a young person, e.g. stress factors, eating disorders, crisis, depression, alcohol and drugs, what it is like to be bullied and how to overcome difficulties.

14. IN THE EFFORT TO TACKLE THE UNDER ACHIEVEMENT OF MANY CHILDREN THROUGHOUT THE EUROPEAN COMMUNITY, WITHOUT PUTTING CHILDREN UNDER UNDUE PRESSURE, AS UNDER ACHIEVEMENT HAS BEEN LINKED WITH ANXIETY AND DEPRESSION.

EXAMPLES  Working with juvenile offenders and adolescents at risk in the community (Portugal) : Under achievement is related to being “far from school culture”, discriminated at school or being without expectations or schooling being able to provide a better future. Under achievement is also related to mental health and is due to both internalising and externalising problems.

15. THERE NEEDS TO BE A PARTICULAR FOCUS ON TACKLING THE PROBLEMS OF STIGMA AND DISCRIMINATION THAT SURROUNDS MENTAL HEALTH PROBLEMS.

EXAMPLES  Dealing with Moods (Netherlands) : Stigma is prevented by focussing on strengths and empowerment and not on depression.

 Life Skills (Sweden) : Addressing suicidal problems is a way to tackle the stigma problem.

16. THERE IS A NEED TO ENCOURAGE MORE TRAINING AND MORE MULTI-PROFESSIONAL NETWORKING ON MENTAL HEALTH ISSUES. EXAMPLES

 Second Step (Norway) : The project was evaluated in the US and an evaluation was started in Norway. Funding is also sought for a project that evaluates the project at a European level.

 Life Skills (Sweden) : The Life Skills Project is evaluated in a quasi-experimental study with a voluntary intervention group and reference group, but plans are under way to evaluate it in a randomised study.

 Love is the Best Kick (Sweden) : The project is evaluated by using four different groups. Two groups were shown the video and the other not. Both groups were then divided into two sub-groups : those who tried to commit suicide and those who did not. The suicidal tendencies had decreased in the group that had watched the video.

17. WHENEVER POSSIBLE NEW AND EXISTING INITIATIVES SHOULD USE AND BUILD ON THE EVIDENCE BASE FROM CONTROLLED, OR PRE AND POST EVALUATION STUDIES, IN ORDER TO DEVELOP APPROPRIATE STRATEGIES, APPROACHES AND PROGRAMMES WHERE THE EVIDENCE BASE AND THE DEVELOPMENT WORK SHOULD BE BASED ON A SUBSTANTIAL AND WELL FOUNDED BODY OF THEORY. FAR MORE PRIORITY SHOULD BE GIVEN TO EVALUATION OF NEW AND EXISTING PROJECTS, WITH AGREAT DEAL MORE RESOURCE DEVOTED TO IT, AND THE CREATION OF MORE EFFECTIVE PARTNERSHIPS BETWEEN PRACTITIONERS AND THE RESEARCH CENTRES WHICH HAVE THE EXPERTISE IN THIS AREA.

EXAMPLES

 Working with juvenile offenders and adolescents at risk in the community (Portugal) : This project always includes professional training and one-year supervision. A manual is always provided. Professionals are also trained, e.g. in Belgium in 2003.

LITERATURE REFERENCES

Andrews, G. 2001. “Should depression be managed as a chronic disease ?” BMJ, 322, 419-421

Catalano, R.F., Berglund, L., Ryan, A.M., Lonczak, H.S. and Hawkins, J. (2002) Positive Youth Development in the United States : Research Finding on Evaluations of Positive Youth Development Programmes. Prevention and Treatment, (5), article 15.

Clarke, G.-N., Hornbrook, M., Lynch, F., Polen, M., Gale, J., Beardslee, W., O’-Connor, E., & Seeley, J. 2001 « A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents », Archives-of-General-Psychiatry, Vol. 58, no. 12, pp. 1127-1134.

Clarke, G., Hawkins, W., Murphy, M., Sheeber, L., Lewinsohn, P., & Seeley, J. 1995, « Targeted Prevention of Unipolar Depressive Disorder in an At-Risk Sample of High School Adolescents : A Randomized Trial of a Group Cognitive Intervention », Journal of American Academy of Child and Adolescent Psychiatry, vol. 34, no. 3, pp. 312-321.

Cohen, J. (1993) Handbook of School Based Interventions : Resolving Student Problems and Promoting Healthy Educational Environments. San Francisco : Jossey Bass.

Dadds, M. R., Holland, D. E., Laurens, K. R., Mullins, M., Barrett, P. M., & Spence, S. H. 1999, « Early intervention and prevention of anxiety disorders in children : Results at 2-year follow-up », Journal of Consulting and Clinical Psychology, Vol. 67, no. 1, pp. 145-150.

Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M., & Laurens, K. R. 1997, « Prevention and early intervention for anxiety disorders : A controlled trial », Journal of Consulting and Clinical Psychology, Vol. 65, no. 4, pp. 627-635.

Downey G., Coyne, J.C. 1990, “Children of depressed parents : an integrative review”, Psychological Bulletin, 108 : 50-76.

Felner, R. D., Brand, S., Adan, A. M., Mulhall, P. F., 1993, « Restructuring the ecology of the school as an approach to prevention during school transitions : Longitudinal follow-ups and extensions of the School Transitional Environment Project (STEP) », Prevention in Human Services, Vol 10, no. 2, pp. 103-136.

Gillham, J., Reivich, K., Jaycox, L., & Seligman, M. 1995, « Prevention of Depressive Symptoms in School Children : Two Year Follow-Up », Psychological Science, Vol. 6, no. 6, pp. 343-351.

Gillham, J. E., Shatte, A. J., & Freres, D. R. 2000, « Preventing depression : A review of cognitive-behavioral and family interventions », Applied and Preventive Psychology, Vol. 9, no. 2, pp. 63-88.

Jaycox, L. H., Reivich, K. J., Gillham, J., & Seligman, M. E. P. 1994, « Prevention of depressive symptoms in school children », Behaviour Research and Therapy, vol. Vol 32, no. 8, pp. 801-816.

Kessler, R., Davis, C. G., & Kendler, K. 1997, « Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey », Psychological Medicine, Vol. 27, no. 5, pp. 1101-1119.

Lister-Sharp D., Chapman S., Stewart-Brown SL., Sowden A. (2000) Health Promoting Schools and Health Promotion in Schools : Two Systematic Reviews. Health Technology Assessment, 3 (22).

McMillan, J. (1992) A Qualitative Study of Resilient At Risk Students : Review of Literature. Virginia : Metropolitan Educational Research Consortium.

Mrazek, P. J. & Haggerty, R. J. 1994, « Reducing risks for mental disorders : Frontiers for preventive intervention research ».Washington : National Academy Press.

Munoz, R. F., Ying, Y. W., Perez-Stable, E. J., & Miranda, J. 1993, « The prevention of depression : Research and practice ». Baltimore : John Hopkins University Press.

Rohde, P., Lewinsohn, P.-M., & Seeley, J.-R. 1991, « Comorbidity of unipolar depression : II. Comorbidity with other mental disorders in adolescents and adults », Journal-of-Abnormal-Psychology, Vol. 100, no. 2, pp. 214-222.

Rutter, M., Hagel, A. and Giller, H. (1998) ‘Anti-social Behaviour and Young People.’ Cambridge : Cambridge University Press.

Stewart-Brown, S. (2000) ‘Parenting, well being, health and disease’. In A.Buchanan and B.Hudson (eds) Promoting Children’s Emotional Well-being. Oxford : Oxford University Press, 28-47.

Weare, K. (2000) Promoting Mental, Emotional and Social Health : A Whole School Approach. Routledge.

Wells, J., Barlow, J. and Stewart-Brown, S. (2001) A Systematic Review of Universal Approaches to Mental Health Promotion in Schools. Health Services Research Unit, University of Oxford Institute of Health Sciences.

Wise, L., Zierler, S., Krieger, N., & Harlow, B. 2001, « Adult onset of major depressive disorder in relation to early life violent victimisation : a case-control study », The Lancet, Vol. 358, pp. 881-887.

World Health Organization, Department of Mental Health (2002) “Preventing Suicide : A Resource for Teachers and Other School Staff”.

World Health Organization, Department of Mental Health (2002) “ Preventing Suicide : a resource for general physicians“.