Opportunities for reducing socioeconomic inequalities in the mental…

Question Answered step-by-step Opportunities for reducing socioeconomic inequalities in the mental… Opportunities for reducing socioeconomic inequalities in the mental health of children and young people – reducing adversity and increasing resilience Jillian Roberts, Angela Donkin and Michael Marmot Jillian Roberts is Research Fellow at the Department of Epidemiology and Public Health, UCL Institute of Health Equity, London, UK. Angela Donkin and Michael Marmot, both are based at the UCL Institute of Health Equity, London, UK. Abstract Purpose – Poor mental health and well-being disproportionately affects vulnerable and disadvantaged children and young people. The paper aims to discuss this issue. Design/methodology/approach – The focus of this paper is socioeconomic inequalities in perinatal, child and adolescent mental health. Findings – Children and young people in the poorest British households are up to three times more likely to develop mental health problems than their more advantaged peers (Green et al., 2005). The pattern can also be observed in the opposite direction, with poor mental health known to contribute to socioeconomic and other health problems (McCulloch and Goldie, 2010, Parckar, 2008). At a larger scale, the higher the level of inequality within developed countries, the higher the rate of child and adolescent mental health problems (Pickett et al., 2006). Social implications – Mechanisms posited as underlying such inequalities include family investment and stress processes. These factors have been taken into account when developing the economic case for investing in perinatal, child and adolescent mental health. Originality/value – Illustrative examples of progressive universal strategies and policies to help reduce socioeconomic inequalities in mental health, include: action to address the inequality gap in the UK; early intervention to improve mental health; investing in sustainable and evidence-based mental health services; ensuring parity of esteem, and; using appropriately designed social media and online sources to support children’s mental health. Keywords Mental health, Well-being, Disadvantaged children, Disadvantaged young people, Socioeconomic inequalities Paper type Viewpoint 1. Introduction The Institute of Health Equity wrote Fair Society, Healthy Lives: the Marmot review (The Marmot Review Team, 2010), and specialise in translating evidence from multiple fields into practical, actionable research and recommendations. This paper is based on a (non-systematic) review of readily available information. We draw upon our experience of writing relevant evidence reviews in this area for practitioners and policy makers. For example, we have written a review of the social determinants of mental health in Europe (Allen et al., 2014), and reviews for Public Health England and the Department of Health on childhood adversity (Allen and Donkin, 2014), school transitions and building resilience in schools (Roberts, 2015a). Received 19 August 2015 Revised 19 August 2015 Accepted 26 August 20154 j JOURNAL OF PUBLIC MENTAL HEALTH j VOL. 15 NO. 1 2016, pp. 4-18, © Emerald Group Publishing Limited, ISSN 1746-5729 DOI 10.1108/JPMH-08-2015-0039 The aim of the paper is to provide an overview of the issue, with some practical suggestions for action. 2. Context All children have the right to a happy childhood and a standard of living sufficient for their mental health, well-being and development (United Nations, 1989). Mental health is also integral to overall health (Allen et al., 2014). Yet in any given year, an estimated one in five children and adolescents in the UK suffer from mental health problems (Mental Health Foundation, 2005), with one in ten children in Britain needing support or treatment for their mental health condition (Green et al., 2005). There are many different types of mental health problems, including anxiety and depression (the most common), as well as obsessive compulsive, eating and personality disorders. Some symptoms, feelings and behaviours are also regularly associated with mental ill-health, such as loss of self-esteem, panic attacks, school disengagement, and an increased risk of intentional self-harm and suicide (Roberts, 2015b). Depression and anxiety are also closely linked to risky health behaviours in adolescence, such as smoking, substance misuse, less exercise and eating an unhealthy diet (The Centre for Social Justice, 2011). In turn, these high-risk behaviours can lead to long-term physical health problems, such as pulmonary disease, obesity and sexually transmitted diseases (Phillips-Howard et al., 2010, Child Welfare Information Gateway, 2013, Fuller and Hawkins, 2014), as well as to an increased risk of developing later on-set diabetes (Department of Health, 2001) and coronary heart disease (Bergh et al., 2015). Although any child is at risk of mental ill-health, good mental health is not equally distributed. Childhood mental illness generally results from a complex interplay between genetic, social and environmental factors. Poor mental health and well-being thus disproportionately affects vulnerable and disadvantaged children and young people including those from the poorest households, disabled children, looked after children, refugee, asylum-seeking, and lesbian, gay, bisexual and transgender children (Allington-Smith, 2006, Reiss, 2013, Green et al., 2005, Heptinstall et al., 2004, Russell and Joyner, 2001, Meltzer et al., 2003). There is also some evidence that ethnicity is linked to child and adolescent mental health status (Choi and Gi Park, 2006, Nguyen et al., 2007). For example, Office for National Statistics (2004) data suggests that Indian children have a relatively low rate of mental disorder (3 per cent, compared with 7-10 per cent in other groups). Since 2010, £85 million has been cut from the budgets of mental health trusts and local authorities across England, with early intervention services hardest hit (Young Minds, 2015, Austin, 2015). At the same time, education professionals and children’s charities are reporting increasing numbers of children and young people with mental health problems, resulting in selfharm, suicidal feelings and attempted suicide. NSPCC’s (2015a) ChildLine, for example, reported a 34 per cent increase in 2013/2014 in counselling sessions for mental health issues, and a survey by the Association of Teachers and Lecturers found that nine out of ten participating schools and colleges have had to provide additional support to pupils with mental health problems over the last few years (Lepper, 2015). This has been attributed to cuts to social services and Child and Adolescent Mental Health services, which many pupils struggle to access (Lepper, 2015). A recent study of 34 North-American and European countries reported a widening socioeconomic gap in adolescent psychological health and reported life satisfaction (Elgar et al., 2015). The government has since pledged £1.25bn over the course of the parliament for child and adolescent mental health services in England (HM Treasury, 2015). Although this is to be commended, to improve the mental health and well-being of all children and young people, while reducing health inequalities, there needs to be a universal and on-going preventative approach: we need to address the social and environmental conditions that lead to poor mental health, and which can lead to children and young people requiring mental health treatment – but with a particular focus on society’s most vulnerable and disadvantaged children and young people. The focus of this paper is socioeconomic inequalities in child and adolescent mental health – so those children and young people living in the poorest households. We also consider perinatal VOL. 15 NO. 1 2016 j JOURNAL OF PUBLIC MENTAL HEALTH j PAGE 5 mental health as this has a large bearing on the mental and physical health of their offspring. The mechanisms posited as underlying such inequalities are also considered, as well as the economic case for investing in perinatal, child and adolescent mental health. We conclude by considering selected strategies and policies to reduce socioeconomic inequalities in mental health. 3.socioeconomic inequalities in mental health There is a clear relationship between lower socioeconomic status (SES) – commonly measured by poverty, low household income, low parental education, and parental occupation status – and mental health problems in children and young people (Reiss, 2013). In Britain, children and young people in the poorest households are up to three times more likely to develop mental health problems than their more advantaged peers (Green et al., 2005). Higher rates of behavioural problems have also been identified among adolescents living in poverty (Dashiff et al., 2009) as well as among pre-school children from low-income families (Qi and Kaiser, 2003). Low household income and low parental education are the measures of SES known to be the strongest predictors of mental health problems – and comorbidity of mental health problems – among children and young people. Entrenched lower socioeconomic position is strongly related to the onset of mental health problems (Costello et al., 1996; Spady et al., 2001). Other indicators of SES, however, are also known to negatively impact children and young people’s mental health. For example, overcrowding is known to negatively impact mental and emotional well-being (Jones, 2010), and more than one in four adolescents living in cold housing are at risk of multiple mental health problems compared to one in 20 adolescents who have always lived in warm housing (Barnes et al., 2008). The impact of low household SES impact younger children more than older – although the effects are seen across all age groups (Esser et al., 1990, Lipman et al., 1996, McGee et al., 1992, McLaughlin et al., 2011). Furthermore, children and young people from disadvantaged backgrounds are more likely to develop comorbidities than their peers (Costello et al., 1996, Spady et al., 2001). The pattern can also be observed in the opposite direction; with poor mental health known to contribute to socioeconomic and other health problems (McCulloch and Goldie, 2010, Parckar, 2008). At a larger scale, the higher the level of inequality in developed countries, the higher the rate of child and adolescent mental health problems (Pickett et al., 2006). Furthermore, socioeconomic inequalities can be enforced because children and young people from more disadvantaged backgrounds, especially with parents with a low education level, are known to have less access to mental health care than those from more advantaged backgrounds (Reiss, 2013). 3.1 Feelings and behaviours associated with poor mental health As would be expected, a social gradient is similarly seen for feelings and behaviours associated with poor mental health – particularly intentional self-harm, suicidal feelings and suicide. Young people in more disadvantaged areas in Scotland, for example, are more likely to commit suicide than those in more affluent areas (Boyle et al., 2005), and the social gradient is most marked among males (Spencer, 2008). Social differentials in adolescent self-harm behaviours have also been identified in some research studies (i.e. Remes and Martikainen, 2015, Kipping et al., 2015, Gunnell et al., 2000). A largely uninvestigated area of research is cyber (or digital) self-harm, whereby young people anonymously “troll” or bully themselves online. Such online behaviours are known to reinforce negative emotions, which can quickly escalate into other harmful behaviours such as suicide (Winterman, 2013). Owing to the identified association between SES and more traditional forms of self-harm, it is important that professionals are trained to identify and/or explore such behaviour in young people, but particularly at-risk groups. A recent paper by IHE has also shown how school disengagement is associated with suicide, suicide risk and self-harm (Roberts, 2015a), with risk of school disengagement strongest for PAGE 6 j JOURNAL OF PUBLIC MENTAL HEALTH j VOL. 15 NO. 1 2016 those vulnerable and disadvantaged pupils who are also at greatest risk of mental health problems (Roberts, 2015a). 3.2 Socioeconomic inequalities and perinatal mental health Perinatal illness is a leading cause of maternal mortality and morbidity in developed countries and has both short- and long-term detrimental impacts on the physical and mental health of both mothers and their offspring if left untreated (Ban et al., 2010, Servili et al., 2010, Bauer et al., 2014). Perinatal mental health problems affect between 10 and 20 per cent of women at some point during the perinatal period (Bauer et al., 2014). Strong socioeconomic inequalities, however, have been found in perinatal mental illness, such that for women of all ages – but particularly older mothers (35-45 years) – the prevalence of depression, anxiety, bipolar disorder, schizophrenia and psychotic disorders, collectively called perinatal mental illness, increases with greater socioeconomic deprivation (Ban et al., 2012). Pregnant women and new mothers across almost half of the UK do not have access to specialist perinatal mental health services (Maternal Mental Health Alliance, 2015): less than 15 per cent of localities provide services at the full level recommended in national guidance, and more than 40 per cent of localities provide no service at all (Bauer et al., 2014). When a mother suffers from mental ill-health, their children face an increased risk of experiencing behavioural, social or learning difficulties (Underdown and Barlow, 2012, Talge et al., 2007, Dawson et al., 2000, Hay et al., 2001), and having their resilience compromised (Field et al., 2006, Langhoff-Roos et al., 2006). This is because unaddressed maternal mental illness in pregnancy and the early years of a child’s life can have an adverse effect on the child’s brain development, as bonding is compromised, and this can lead to poorer long-term health and other social outcomes (Hogg, 2013). The children of mothers experiencing mental illness are also at increased risk of prematurity and low birth weight (Seng et al., 2011, Smith et al., 2007, Talge et al., 2007), which increases the risk of trans-generational transmission of depression (Surkan et al., 2011). Premature or low birth weight babies have an increased risk of mortality, as well as neurodevelopment problems, ill-health, suboptimal growth and long-term negative cognitive outcomes (Wilcox and Skjaerven, 1992, Hack et al., 1995). 4. Mechanisms posited as underlying socioeconomic inequalities in child and adolescent mental health A number of theoretical approaches have been established to explain socioeconomic differences in perinatal, child and adolescent mental health. First is the social causation hypothesis that SES affects families and children’s mental health in terms of the ability of parents to afford certain goods and experiences thought to be beneficial to children’s mental health and well-being (the family investment model), and the impact that economic hardship has on parenting ability, via economic stress (the family stress model). Second is the social selection hypothesis that parents who suffer from mental health problems fall down the SES ladder, which, in turn, affects their children’s mental health. 4.1 Social causation hypotheses 4.1.1 Family investment model. The family investment model proposes that absolute poverty and a lack of resources can negatively impact a family’s capacity to provide for their children adequate nutrition and opportunities for physical activity, good quality housing, and sufficient hygiene and safety. It can also influence their child’s ability to maintain self-esteem – on- and off-line – through material goods and being able to engage in the same rewarding experiences as their peers: I’m nervous about getting bullied and getting lost [at secondary school]. There is a girl, she thinks I’m acting like a boy – but I’m not – ’cause I wore trousers […] I wanted a skirt for ages. My mum couldn’t afford a skirt so I wore trousers (Holloway et al., 2014). VOL. 15 NO. 1 2016 j JOURNAL OF PUBLIC MENTAL HEALTH j PAGE 7 Disadvantaged and vulnerable children and young people are more likely to live in families with limited access to financial, social and natural sources that protect mental health, and have higher exposure to risk factors that are detrimental to mental health. This can significantly impact upon families’ and communities’ drive and capacity to make healthy decisions and engage with health and social care services. These risk and protective factors operate at different levels: individual factors (such as genetic makeup and lifestyle behaviours), family and community factors (such as parenting, income, housing, access to green space, hygiene, adequate diet, safety and strong social networks), and societal and environmental conditions (such as health care provision, education and unemployment levels). An important point to note is that people in poverty are not always in poverty and cross-sectional snapshots of data can mask this – circumstances change. For example, researchers have found that parental unemployment is associated with a two- to three-fold increased rate of onset of emotional/conduct disorder in childhood (Green et al., 2005). Persistent poverty should also be distinguished from current poverty: while persistent poverty significantly predicts internalising symptoms, such as anxiety and depression, current poverty predicts externalising symptoms such as aggression and oppositional defiance (Murali and Oyebode, 2004). Levels of societal inequality, resulting in differences in access to material goods and the ability to afford rewarding experiences, can also affect how people feel (emotional well-being). When there is a large gap between the “haves” and the “have nots”, social cohesion is eroded, and people with limited resources are more likely to feel anxious and insecure, with decreasing trust and self-esteem (Wilkinson, 2005, Wilkinson and Pickett, 2006). Children and young people are known to particularly suffer in terms of their health as a result of growing socioeconomic inequality (Currie et al., 2008, Holstein et al., 2009). Social media and online resources – although often a source of help for children and young people – have the unfortunate potential to exacerbate inequalities in mental health. With children and young people placing increasing value on looking good in the eyes of others, both in person and online – i.e. through Facebook “likes” and twitter followers, or even through being persuaded to pose for intimate pictures – they are at greater risk of depression, anxiety, negative overall life satisfaction and engaging in substance misuse, particularly if they feel jealousy or shame at being unable to keep up with their peers in terms of social status (Kross et al., 2013, Cookingham and Ryan, 2015, Przybylski et al., 2013). Bullying and “fear of missing out” – anxiety that others are having rewarding experiences that they are absent from, or being unable to afford goods that others have – might also affect mental well-being (Kross et al., 2013, Cookingham and Ryan, 2015, Przybylski et al., 2013). 4.1.2 Family stress model. The family stress model theorises that economic difficulties causes stress, anxiety and depression for parents through, for example, their inability to find sufficient employment and pay household bills, and that this in turn impacts their parenting abilities (Conger et al., 2000). Income is strongly associated with types of maternal psychological functioning that promote self-esteem, positive behaviour and better physical health in children (Gregg et al., 2008). It is therefore likely that poverty inhibits family processes of informal social control, in turn reducing parents’ emotional availability to meet their children’s needs and increasing the risk of parental conflict and harsh parenting – for example, using physical punishment or being unresponsive towards their children (Conger et al., 2000). 4.2 Social selection theory The social selection – or “social drift” – hypothesis argues that poor health impacts people’s social mobility and ultimately their SES. Epigenetics posits that some people are genetically predisposed to poor health and are more vulnerable to adverse environments. Social selection results in these people drifting down to – or failing to rise up and out from – a low social position (Jarvis, 1971, Blane et al., 1993). There is, however, evidence, of an association between both social causation and social selection hypotheses (Reiss, 2013). PAGE 8 j JOURNAL OF PUBLIC MENTAL HEALTH j VOL. 15 NO. 1 2016 5. The impact of poverty and stress on child and adolescent mental health outcomes As described above, poverty and economic stress can exacerbate both negative parental behaviours, as well as adverse social and economic environments in which children and young people are born and develop. In a sizeable minority of cases, poverty and economic stress can lead to infants, children and young people experiencing neglect, and/or being exposed to other adverse childhood experiences (ACEs); all of which can have a significant impact on their mental health and development. In this section, we also briefly consider the pathways through which poverty and stress experienced by the mother during the perinatal period can lead to her child experiencing short- and long-term mental health problems. These are discussed, in turn, below. 5.1 Neglect and exposure to ACEs Children and young people who live in poverty, unsuitable housing or in a more disadvantaged area are more likely than their peers to suffer neglect (Thoburn et al., 2000). Neglect can be categorised as physical or supervisory, psychological, medical or educational neglect; although the four forms of neglect often co-occur (National Scientific Council on the Developing Child, 2012). Housing and money worries can place considerable stress on families, and prevent parents from being able to provide the practical and emotional support that their children need (NSPCC, 2015b). Children and young people who live with a parent with substance misuse problems, who are in a domestically abusive relationship, or with mental health problems – all of which follow a social gradient (Blass and Kurup, 2010, Marmot, 2015, Allen et al., 2014) – are also more likely to suffer neglect as a result of the impact on parenting ability (NSPCC, 2015b). In turn, children who are neglected are more likely to experience mental health problems, including depression and PTSD (NSPCC, 2015b), while persistent neglect can lead to serious impairment of health and development, as well as long-term difficulties with social functioning, relationships and educational outcomes. In extreme cases, neglect can also result in death (Sidebotham, 2007). This is because neglect can severely alter the way a child’s brain works, which can lead to an increased risk of poor mental health (Child Welfare Information Gateway, 2013). Principally, neglect can lead to persistent activation of stress response systems in the developing child, which can disrupt and weaken “brain architecture” (National Scientific Council on the Developing Child, 2012). Over time, chemicals released as a result of this disproportionate stress response can lead to mental and other associated health problems (National Scientific Council on the Developing Child, 2012). Children who suffer extreme levels of neglect show weakened electrical activity in the brain, measured through electroencephalography (Marshall et al., 2004, Tarullo et al., 2011), which in turn affects the development of the two main biological stress systems: the sympathetic-adrenal-medullary system that produces adrenaline and affects heart and respiration rates, and the hypothalamic-pituitary-adrenal axis that controls cortisol levels. Disruption to healthy development of these biological stress systems can compromise children’s ability to cope with adversity, which can lead to greater risk for anxiety, depression and related health problems later in the child’s life (National Scientific Council on the Developing Child, 2012, Gunnar et al., 2009). Parental absence and divorce, physical and mental illness in the household, as well as other forms of maltreatment (i.e. physical, sexual and emotional) – collectively known as ACEs – also relate to stress and follow a social gradient. Exposure to ACEs can increase the risk of children and young people experiencing mental illness or a low-level of mental well-being, including self-esteem, depression and relationship difficulties (Child Welfare Information Gateway, 2013, Higgins and Mccabe, 2000, Gruber and Fineran, 2007). In a study of the impact of childhood adversity on psychopathology, risk of mental illness as a result of exposure to ACEs was shown to be greatest if the exposure was at a younger age (Clark et al., 2010). This was true for most forms of ACE bar sexual and physical abuse (emotional abuse was not considered in the study), where the rise of mental ill-health increased over the life course (Clark et al., 2010). Multiple and cumulative adversities (exposure to three or more ACEs), is known to have the greatest impact, increasing risk of poor mental ill-health (psychopathology) at ages 16, 23 and 45 years (Clark et al., 2010). VOL. 15 NO. 1 2016 j JOURNAL OF PUBLIC MENTAL HEALTH j PAGE 9 5.2 Perinatal mental illness History of depression is one of the strongest risk factors for perinatal depression, but the impact of financial difficulties, independent of prior mental ill-health, is a contributing factor (Ban et al., 2012, Solari and Mare, 2012), such that the stress caused by issues such as poor housing, low income or poverty, and limited social support can exacerbate symptoms of anxiety and depression for pregnant or new mums (Hogg, 2013). Conversely, mental ill-health can contribute to other forms of disadvantage, such as risk of unemployment, low income and marital conflict (social causation hypothesis (Dohrenwend and Dohrenwend, 1969)), which indirectly can negatively affect children’s health (O’Donnell et al., 2014). Research suggests that the stress chemicals produced by women with mental ill-health during pregnancy pass through the placenta into the womb and affect fetal development. In turn, exposure to stress hormones in the womb is believed to affect the child’s own stress response system which can alter the way they behave and respond to stress and stimuli when born and experiencing the world around them (Hogg, 2013). In some circumstances – notably if perinatal mental health problems significantly impair the parents’ ability to provide responsive parenting, or if the illness leaves the family isolated or contributes to parental conflict – children are at increased risk of abuse or neglect (Hogg, 2013). We also know that maternal stress and being a young mother can lead to lower levels of breastfeeding initiation (Wolfe et al., 2014), which is associated with adverse developmental and health outcomes for children across the life course (Pordes-Bowers and Strelitz, 2012). 6. The economic case for investing in children and young people’s mental health There is strong and compelling economic evidence for addressing child and adolescent mental health. For example, the estimated lifetime cost of severe behavioural problems and ADHD is £260,000 per child, and £1,070 million for each one-year cohort of children in England, respectively – based on use of health and social care services, educational provision, crime and reduced lifetime earnings (2012/2013 prices) (Parsonage et al., 2014) – compared with the average estimated cost of delivering a 8-12 week parenting programme for the prevention of persistent conduct disorders, such as Triple P and Incredible Years, which is around £1,213 per family (Curtis, 2014, based on 2013/2014 prices). Effective and cost-effective mental health programmes include school-based interventions, which have been shown to improve children’s behaviour and outcomes, and have an estimated benefit to cost ratio of 27:1 (The Social Research Unit, 2015), as well as Functional Family Therapy, which targets at-risk young people and trains their families to effectively negotiate and set rules and responsibilities. The benefit to cost ratio, for the USA, was estimated at 12:1 (Washington State Institute for Public Policy, 2014), although it is difficult to compare costs between countries because of fundamental differences in health and social care systems. The costs of perinatal depression with anxiety and psychosis are also extremely high: estimated at £8.1bn for each one-year cohort of births in the UK – equivalent to just under £10,000 for every single birth in the country (Bauer et al., 2014). Nearly three-quarters of this cost (72 per cent) relates to adverse impacts on the child as opposed to the mother or family, and are largely associated with costs to health and social care services (Bauer et al., 2014). On the other hand, a cost of around £400 per average birth would help to provide the additional NHS expenditure needed in England to bring perinatal mental health care up to the level and standard recommended in national guidance (Bauer et al., 2014). 7. How can we reduce inequalities in children’s mental health? 7.1 Reducing the inequality gap in the UK The more equal the country, the better the population’s mental and physical health. There is evidence that improvements in socioeconomic conditions result in a significant reduction of mental health problems (Strohschein, 2005, Esser et al., 1990, Goodman and Huang, 2001, Costello et al., 2003). This suggests that efforts to bolster income and improve access to PAGE 10 j JOURNAL OF PUBLIC MENTAL HEALTH j VOL. 15 NO. 1 2016 financial, social and natural resources for at-risk, low-income families may help to reduce mental ill-health among disadvantaged children and young people. If the inequality gap continues to widen in the UK, we can expect an even greater demand for mental health services. To this end, it is imperative that welfare reforms take into consideration the fact that inequality affects the whole population, but that vulnerable and disadvantaged children and young people are at greatest risk and will therefore need additional support to both prevent and treat mental health conditions. 7.2 Early intervention is key to improved mental health and reduced inequalities Starting in pregnancy, perinatal mental ill-health and vulnerability to mental ill-health need to be identified and addressed at the earliest possible opportunity. Mental illness in pregnant and new mothers needs to be effectively prevented, detected and treated, with mothers supported to provide positive parenting, and a safe and nurturing home learning environment for their offspring. As any mother can be at risk of perinatal mental illness, and any child consequently at risk of negative health outcomes, universal services – including midwives, GPs, children’s centres and health visitors – have important roles to play in both supporting women’s mental health during pregnancy and the early years, but also in identifying at-risk mothers and children, and providing additional support at the earliest opportunity. Preventative work to improve the conditions in which mothers live and/or work – as set out in the Marmot Review – should translate into improvements in maternal mental health (Allen and Donkin, 2014). There is also evidence to support the use of targeted psychological interventions (i.e. group psycho-education), for women who are depressed or who have symptoms of depression and anxiety (Barlow et al., 2008). Furthermore, there needs to be equitable access to specialist perinatal mental health services, which currently is not the case. Furthermore, there is strong evidence that the sooner neglected children receive appropriate intervention, the less likely they are to demonstrate long-term, and adverse health outcomes (National Scientific Council on the Developing Child, 2012). Finally, within schools and early years education, teachers and professionals need to be adequately trained to identify the early warning signs of mental ill-health. 7.3 Invest in sustainable and evidence-based mental health services Good quality, sustainable mental health services for pregnant and new mothers, and children and young people need to be further invested in, not cut back. This paper shows how poor adolescent mental health is associated with an array of poor – and costly – health outcomes across the life course. A failure to address child and adolescent mental health will result in substantial human and financial costs building up for the future. There are a number of evidence-based programmes that can be delivered in non-clinical settings, which are often preferred by vulnerable groups (Vulnerable Groups and Inequalities Task and Finish Group, 2015), such as the school-based Good Behaviour Game, which has been shown to reduce aggressive behaviours (benefit to cost ratio of 27:1) (The Social Research Unit, 2015). Programmes including Triple P Positive Parenting, Family-Nurse Partnership and Incredible Years have also shown to be both good value and effective at reducing abuse and neglect, and improving child and adolescent mental health (The Social Research Unit, 2015). Furthermore, systematic reviews have found that individual and group CBT delivered to young people in secondary schools can reduce the symptoms of depression and anxiety, and have high benefit to cost ratios (31:1) (The Social Research Unit, 2015). Measuring the impact of CBT and other mental health interventions on health inequalities, however, is problematic owing to methodological challenges (Kavanagh et al., 2009). This should thus be the focus of future research and evaluation studies. 7.4 Parity of esteem between mental and physical health Research has shown that mental health is as important as physical health for overall health and well-being; indeed the two are tightly intertwined (Royal College of Psychiatrists, 2013). A more VOL. 15 NO. 1 2016 j JOURNAL OF PUBLIC MENTAL HEALTH j PAGE 11 integrated mental and physical health approach, that also incorporates support from services that impact on inequalities, such as housing and employment, will have the greatest impact on improving child and adolescent’s mental health, and reducing inequalities. 7.5 Use appropriately designed social media and online sources for good Despite concerns that social media has a detrimental impact on children and young people’s mental health, there is also evidence that online communications and social media can be a helpful resource (Cookingham and Ryan, 2015, Best et al., 2014, Blenkinsop, 2014). Children and young people who are experiencing mental health problems are increasingly turning to the internet and social media for support, instead of health professionals, teachers or their parents (Blenkinsop, 2014). For example, online comic blogs, such as Hyperbole and a Half and the Doodle Chronicles offer an online support community for young people suffering mental ill-health. A systematic review, however, found that further research is required to understand how social media can be most effectively designed to promote the mental health care and support of young people (Best et al., 2014). Nevertheless, mental health and other professionals, including teachers, should understand that children and young people often feel most comfortable accessing online mental health support, and should therefore utilise or signpost to useful online resources, such as that offered by Young Minds, ChildLine and MindEd. They should also help to ensure that all, but particularly disadvantaged or vulnerable children, have equitable access to quality online resources, and in environments that are conducive to self-care. 7.6 Further research into genetics, and impact of interventions to reduce effects of poverty It appears that there is likely to be merit in determining if there is clustering of genetic factors within different socioeconomic groups. There is a field of genetic research that has looked at heritability and this could potentially be extended. Such analyses would help inform policy makers as to the relative contribution that action on environmental factors could have to reducing inequalities in mental ill-health prevalence. Given that the current effect sizes cannot be used to predict outcomes, however, we believe that the effect is likely to be marginal, and therefore because of this, and because genetics cannot be changed, action needs to focus on environmental factors, and the relationship between environmental factors and DNA modification/expression (epigenetics). Also it seems that where research money is available, identifying interventions that effectively work to reduce the impact of poverty, would be of interest. Of course the ethical guidelines would be complex here, but a longitudinal research programme aligned with investment in schools and with families to mitigate against the negative impacts of poverty would be of value. An analysis of the different uses of the pupil premium – additional funding to raise the attainment of disadvantaged pupils in publicly funded schools in order to close the gap between them and their peers – within schools, would be a good course here and could highlight the most effective methods of utilising the pupil premium for reducing prevalence of mental ill-health. References Allen, J., Balfour, R., Bell, R. and Marmot, M. (2014), Social Determinants of Mental Health, World Health Organisation, Geneva. Allen, M. and Donkin, A. (2014), The Impact of Adverse Experiences in the Home on the Health of Children and Young People, and Inequalities in Prevalence and Effect, Institute of Health Equity, London. Allington-Smith, P. (2006), “Mental health of children with learning disabilities”, Advances in Psychiatry Treatment, Vol. 12 No. 2, pp. 130-40. Austin, M. 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(2004), “Epigenetic programming by maternal behavior”, Nature Neuroscience, Vol. 7 No. 8, pp. 847-54. Wood, J. (2011), “School absenteeism, mental health problems linked”, available at: http://psychcentral. com/news/2011/12/25/school-absenteeism-mental-health-problems-linked/32937.html (accessed 31 July 2015). Wood, J.J., Lynne-Landsman, S.D., Langer, D.A., Wood, P.A., Clark, S.L., Eddy, J.M. and Ialongo, N. (2012), “School attendance problems and youth psychopathology: structural cross-lagged regression models in three longitudinal data sets”, Child Development, Vol. 83 No. 1, pp. 351-66. Young Minds (2014), “Are young people turning to social media for mental health support?”, available at: www.youngminds.org.uk/news/blog/1792_are_young_people_turning_to_social_media_for_mental_ health_support (accessed 31 July 2015). Corresponding author Angela Donkin can be contacted at: a..n@ucl.ac.ukQUESTIONS: PURPOSE: 1.Tutor How can you please help me how to Demonstrate an understanding of the nursing process and the teaching-learning principles as applied to nursing practice to promote health related to an identified Sustainable Developmental Goal.2.Tutor what is the Use evidence-based information and research to support the need for education and health promotion related to the identified Sustainable Developmental Goal.3.tutor in this article how can Facilitate the development of a Teaching and Learning (nursing process) template and presentation to share with your peers to practice your public speaking and presentation skills.4.tutor i dont know how to Synthesize the role of the nurse and the importance of promoting Global Health through education and actionAssessmentDiagnosisPlanningImplementation/strategiesEvaluationFrom the literature:a)Definition of …b)Incidence of…c)Ways to promote changed)Ways to teache)Ways to evaluateKnowledge deficit related to the SDG’s as evidenced by…a)Plan to introduce this SDG.b)Plan to introduce the incidence and problems related to this…c)Plan to promote information that is attempting to conquer thisd)Plan to evaluate learner knowledge before and after presentation related to XXXX and how?a)Introduce the SDG by… talk, power point,brochure, pamphlet etcb)Provide information related to incidence and problems by… Health Science Science Nursing IEPN 125 Share QuestionEmailCopy link Comments (0)