The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0965-4283.htm

HE
108,4 Supporting children’s emotional
wellbeing and mental health in
England: a review
272
Claire Maxwell, Peter Aggleton, Ian Warwick and Ekua Yankah
Thomas Coram Research Unit, The Institute of Education,
Received 27 June 2007
Revised 5 December 2007 University of London, London, UK
Accepted 5 December 2007 Vivian Hill
School of Psychology and Human Development, The Institute of Education,
University of London, London, UK, and
Dina Mehmedbegović
The London Centre for Leadership in Learning, The Institute of Education,
University of London, London, UK

Abstract
Purpose – This paper aims to inform the development of policies and programmes to support
children and young people’s emotional wellbeing and mental health. It seeks to bring together findings
both from recent systematic reviews, and from individual evaluation studies which have adopted a
relatively rigorous methodology but whose findings have not to date been included in such analyses.
Research undertaken in England is to be prioritised, to complement an existing evidence base
comprised largely of findings from US-based research.
Design/methodology/approach – Using five key search strategies, studies were categorised into
three main categories – “demonstrably effective approaches”, “promising approaches” and
“approaches for which there is little or no supporting evidence” – according to robustness of
evidence. Overall, 171 potentially relevant studies were identified, with 20 of these being robust
enough for inclusion in the final review.
Findings – In schools, sustained broad-based mental health promotion programmes combined with
more targeted behavioural and cognitive-behavioural therapy (CBT) for those children with
identifiable emotional wellbeing and mental health needs, offer evidence of a demonstrably effective
approach. Early and brief intervention programmes which reduce waiting times for services appear
promising approaches and seem to reduce the number of sessions a family require. There is a
reasonably strong evidence base to support targeted work with both parents and children.
Practical implications – By providing a detailed description of the successful initiatives reviewed,
this paper should help policy-makers and practitioners to develop their work.
Originality/value – By complementing the relatively narrow evidence base offered by systematic
reviews, this more broadly based review offers policy-makers and practitioners in England an
up-to-date, context-relevant guide for programme development within this field.
Keywords Mental health services, Psychology, Children (age groups), Youth, Evidence, United Kingdom
Paper type Literature review
Health Education
Vol. 108 No. 4, 2008
pp. 272-286 Introduction
q Emerald Group Publishing Limited
0965-4283
Promoting the emotional wellbeing and mental health of children and young people is a
DOI 10.1108/09654280810884160 key aspect of English government policy. The two key strategy documents informing
work with children and young people in England – Every Child Matters and the Supporting
National Service Framework for Children, Young People and Maternity Services – children’s
specify the importance of work to promote children’s mental health and psychological
wellbeing (Department for Education and Skills, 2003; Department of Health, 2004). wellbeing
The increasing prominence being given to emotional wellbeing and mental health calls
for a strong evidence base to inform policy and practice.
Currently, professionals working in England have access to a number of systematic 273
reviews through publications such as those by Davis et al., 2000; Fonagy et al., 2002;
Wolpert et al., 2006 or via web sites such as The Cochrane Collaboration (www.
cochrane.org/index.htm) and the National Library for Health (www.library.nhs.uk/
Default.aspx). These studies report on largely psychiatric interventions (both drug and
therapeutic), which have been found to be effective with children and young people
with diagnosed mental disorders (as defined by the International Classification of
Diseases, tenth revision (ICD-10)). Yet, government policy and many practitioners are
keen to support children and young people who are experiencing difficulties in relation
to their emotional wellbeing, not only those with a diagnosable mental disorder.
Furthermore, the prevention of mental health problems and the “promotion” of
emotional wellbeing and mental health has also become a focus for work. To inform
this broader and more preventive framework for action in England other reviews of
evidence are likely to be valuable, especially those which focus on ways of supporting
children, young people and families in non-clinical settings.
A small number of systematic reviews exist which have the promotion of emotional
wellbeing and mental health as their focus (Durlak and Wells, 1997; Wells et al. 2003;
Green et al., 2005) or which examine effective interventions in non-clinical settings
(Durlak and Wells, 1998; Farmer et al., 2002; James et al., 2005; Topping and Flynn,
2007). However, for English policy-makers and practitioners there are two main
difficulties in developing work using these existing reviews. First, the inclusion criteria
used for studies to be included in these reviews are narrowly focused (in order to align
with the requirements of a systematic review). This limits the extent to which
potentially relevant findings from newer or less well evaluated interventions are
integrated into the available evidence base informing policy and practice
(Rycroft-Malone et al., 2004). Second, very few of the studies included in the above
systematic reviews have been conducted in England. The demographic, policy and
service context of the USA (where the majority of studies which are included in
systematic reviews in this field have been undertaken) is different enough to make
transferability of research findings problematic (Edwards, 2003; Public Health
Institute of Scotland, 2003).
A review was therefore undertaken which aimed to build on the evidence base
offered by systematic reviews but also to tackle the above mentioned gaps in
knowledge. The review took as its starting point the broad term “emotional wellbeing
and mental health” rather than the more narrowly defined term “diagnosable mental
disorder”. The review also prioritised the inclusion of evaluation studies undertaken in
the UK so as to provide English policy-makers and practitioners with information
about programmes which might work in promoting children and young people’s
emotional wellbeing and mental health, in demographic, policy and service contexts
with which they were familiar. Finally, the review integrated evidence from current
systematic reviews with an analysis of findings from other evaluation studies. This
HE paper reports on key findings from the review. It focuses in particular on the kinds of
108,4 programmatic approaches that are likely to be most successful in supporting the
emotional wellbeing and mental health of children and young people when delivered
outside a clinical or hospital setting.

Methodology
274 Search strategies
Five principal search strategies were utilised:
(1) A search was undertaken of four on-line bibliographic databases: Medline,
PsycInfo, ERIC (Educational Resources Information Centre) and Social Science
Abstracts using the following key words and combinations of them: emotional
wellbeing, mental health, mental health problems, mental illness, emotional and
behavioural difficulties, emotional problems, psychology, psychiatry,
psychiatric disorder, antisocial behaviour, disability, children, young people.
(2) A manual search was completed of 19 good quality international journals – the
journals were chosen so as to cover a range of disciplines concerned to some
extent with child emotional wellbeing and mental health (including Child and
Adolescent Mental Health, Clinical Child Psychology and Psychiatry, Australian
e-journal for the Advancement of Mental Health, the International Journal of
Mental Health Promotion, Emotional and Behavioural Difficulties, Health
Education, Health Education Journal, and the British Medical Journal ).
(3) A search was undertaken of 18 web sites relevant to work with children and
young people, emotional wellbeing and mental health (including web-based
databases of published research such as Current Educational Research in the
UK and the National Electronic Library for Health; the English government’s
Department for Education and Skills and Department of Health Research
Publications; UK organisations such as National CAMHS Support Service, The
Royal College of Psychiatrists; and relevant university departments such as
CAMHS Evidence Based Practice Unit and the Centre for Outcomes Research
and Effectiveness at University College London).
(4) E-mail and telephone contact was made with mental health professionals based
in London to access further “grey” literature (i.e. research and reports not
published in peer-reviewed journals)
(5) Key references identified through the above four search strategies were
followed up on so as to access literature not otherwise identifiable using the
above search strategies.

Inclusion and exclusion criteria

Unless otherwise stated above, the following inclusion criteria were used when
searching databases, journals and web sites. Research should be:
.
published in English between 2000 and 2007;
.
in the form of systematic literature reviews, meta-analysis, other literature
reviews, evaluation studies, randomised controlled trials, pilot studies,
interventions;
.
focused on children and young people aged between three and 18 years old;
 .
concerned with emotional wellbeing and mental health (or mental disorder and Supporting
other related terms) and children, young people and/or parents; children’s
.
focused on research or programmes taking place in schools or in wellbeing
(community-based) child and adolescent mental health services (CAMHS).

The review was concerned to prioritise research from England and other parts of the
UK so as to complement existing research from the USA (Evans, 1999; Rones and 275
Hoagwood, 2000), Australia (Davis et al., 2000) and other countries (Mukoma and
Flisher, 2004) published elsewhere, and to maximise the relevance of findings for
English policy-makers and professionals. In this review, findings from studies
conducted in the USA, Canada and Australia are included only if they focus on
programmes in schools or community-based mental health support services which
demonstrate some evidence of effectiveness in relation to promoting or supporting
emotional wellbeing and mental health, and where there was very little or no UK-based
research on similar initiatives.
Studies which focused specifically on Attention Deficit and Hyperactivity Disorder,
autism and neuro-developmental disorders, as well as substance use were excluded to
ensure sharper focus on broader emotional wellbeing and mental health issues in two
settings of special interest – namely, schools and community mental health support
services.

Categorisation and analysis

Studies were initially grouped according to the following categories: systematic
reviews; other literature reviews; individual evaluation studies with a control/waiting
list group; individual evaluation studies; and articles or reports describing services or
service provision. In order to build on the knowledge base offered by existing
systematic reviews, a second stage of analysis involved categorising studies into three
groups (representing variable levels of strength of evidence): demonstrably effective
approaches; promising approaching; and approaches which offered variable or no
evidence of success in leading to improved outcomes for children, young people and/or
their families in relation to emotional wellbeing and mental health. Only studies falling
into the first two categories have been included in this paper.
“Demonstrably effective approaches” were those identified from the findings of
systematic reviews. The research team examined the systematic review authors’ own
conclusions about the degree of confidence with which they were able to make
recommendations about effective approaches to inform the decision about which
category of evidence the systematic review study should be accorded.
Programmes categorised as “promising approaches” were drawn both from
systematic review studies and from individual evaluation studies. If systematic
reviews concluded that while the evaluated programmes they assessed could lead to
positive outcomes, but that findings to date were only tentative, these programmes
were categorised as “promising approaches”.
Individual evaluation studies were only included in this category of evidence if more
than one study of the same or a similar programme had been undertaken and had
found a positive impact on emotional wellbeing and mental health (which had been
sustained over time), and the evaluation research design was methodologically
rigorous. For the purposes of this review, studies were considered methodologically
HE rigorous if at least two of the three following criteria were met: a
108,4 comparison/control/waiting list group was used; children and young people were
followed over a period of time after completion of the programmes (at least three
months); and recognised measures of emotional wellbeing and mental health were
used.
Following the first stage of analysis, altogether 131 references were identified as
276 relevant to answering the question – what programmes appear to support children
and young people’s emotional wellbeing and mental health? Following the second
stage of analysis, 111 articles and reports were excluded. There were five main reasons
for doing this. First, non-systematic literature reviews identified for this paper did not
outline the methodology used to reach their findings – so these were used only to check
the current paper’s conclusions, rather than a primary source of evidence. A second
reason for excluding a study was if the research had been conducted in a country
outside the UK and enough UK-based studies on that particular issue had been
identified and included in the review already. Third, on closer inspection, the reported
study either used such a weak methodology it was not felt to offer strong enough
evidence for inclusion in the review, or too little information was given about the
evaluation methodology used and outcome data generated. Fourth, an article was
excluded if it did not report on original research but took the form of a commentary on
recent policy or practice developments. Finally, if an article or report focused only on
children and young people as in-patients in a mental health service or presented a
review of effective treatments for a diagnosable mental disorder, these were also
excluded. In total, 20 studies and reports remained and findings from them are reported
on subsequently.
Following the completion of the second stage of analysis, we examined whether the
studies appeared to cluster into particular types of programmes. Work in schools,
initiatives aimed at assessing and providing some support early on to children and
families experiencing difficulties, and programmes targeted at parents (as well as
children) appeared to be the three main areas in which some evidence of effectiveness
could be found.

Findings
Table I summarises the main findings of the review. This is then followed by a more
detailed description of the studies and programmes included in the review.

Supporting emotional wellbeing and mental health in schools

Four systematic reviews focused on emotional wellbeing and mental health in school
settings were identified in the literature search and offered evidence of demonstrably
effective approaches. Durlak and Wells (1997), for example, reviewed 177 programmes
designed to prevent behavioural and social problems in children and young people
living in the USA. Three types of prevention programmes produced significantly high
effects: those that modified the school environment, those that focused specifically on
meeting the needs of individual children and young people (especially those using
behavioural and cognitive behavioural strategies), and those that attempted to help
children and young people negotiate stressful transitions.
In 2003, Wells and colleagues reviewed studies which evaluated a universal
approach to promoting emotional wellbeing and mental health, and compared these
 Supporting
Type of Strength of
programme evidence Description of effective or promising initiatives children’s
Work in schools Demonstrably Multi-component and universal programmes which aim to
wellbeing
effective promote emotional wellbeing and mental health (rather
than prevent “mental illness”), which are sustained over a
period of over one year and which focus on modifying the 277
school environment and developing adaptive cognitive and
behaviour strategies for pupils. Alongside this universal
approach, targeted cognitive-behavioural therapy (CBT)
work with children and young people who have identified
needs
Promising For pupils with emotional wellbeing and mental health
problems (specifically anxiety), a CBT programme called
FRIENDS (developed in Australia)
Early assessment Demonstrably No programmes reviewed offer this strength of evidence
and support effective
Promising Programmes, which offer children (and their families) an
initial assessment by trained professionals (not necessarily
a clinical psychologist or psychiatrist) as soon as possible
after being referred for support. A number of these
initiatives also offer families a small number of initial
support sessions. CBT work with children and young
people is likely to be effective in such types of initiatives
Working with Demonstrably CBT work with parents has received strong support from
parents effective systematic reviews but the relative merits of different
models of CBT have yet to be determined
Promising Initiatives which work with and support parents (usually Table I.
at the same time as offering a service to the child or young Key findings from
person) the review

with programmes that took a more “problem prevention” focus in schools (primary and
secondary schools). All except two of the reviewed studies had been conducted in the
USA. Using a relatively strict set of inclusion criteria, only 17 studies (evaluating 16
programmes) were included in the review. Positive evidence of effectiveness was
obtained for programmes that adopted a whole-school approach, were implemented
continuously for more than a year, and were aimed at the promotion of emotional
wellbeing and mental health and focused on changing the school environment. Little
evidence was found to support brief classroom-based programmes aimed at preventing
“mental illness” (Wells et al., 2003, p. 197).
Green et al. (2005) reviewed those systematic reviews specifically focused on the
effectiveness of school-based interventions in promoting the social and emotional health
and wellbeing of primary school-aged children. Eight systematic reviews met the
inclusion criteria for Green et al.’s (2005) analysis which included the two reviews already
referred to above. Green et al. (2005) also concluded that a promotional rather than
prevention approach was more effective, as were initiatives aimed at changing the school
environment rather than brief classroom-based, individually focused programmes.
Finally, Rones and Hoagward (2000) evaluated 47 school-based interventions
specifically designed to influence students’ emotional, behavioural, and/or social
HE functioning. Most of the studies reported on work conducted in the USA. The authors
108,4 concluded that there were no particular right or wrong activities that made up
successful school-based interventions, but that a number of common factors should
inform the development of programmes. These include consistent programme
implementation; the inclusion of parents, teachers and peers; the use of different types
of programmes (such as those focused on behaviour, emotions and cognitive process,
278 and the environment); the integration of programme content into general classroom
curricula; and the adoption of age- and developmentally-appropriate programme
components.
Alongside these broad programmatic recommendations from systematic reviews,
one specific programme, the FRIENDS Programme, appears to offer a promising
approach. This is a ten-session cognitive-behaviour therapy (CBT) programme for
children and young people with anxiety delivered in schools either by teachers, nurses
or psychologists. Stallard et al. (2007) have also described the FRIENDS programme as
“a universal preventative emotional health programme” (p. 33). Barrett et al. (2006)
(following on from previous studies that demonstrated the positive impact of FRIENDS
on children aged ten to 13 years old over a 12-month period) used a control-group
design and a three-year post-programme follow-up of 692 children and young people.
The main findings from this Australian study was that participation in the FRIENDS
programme significantly reduced anxiety and depression symptoms, particularly
among the younger age group (those aged nine to ten years old with more modest
impacts registered by young people aged 14-16 years old). Even three years following
the ten-week programme, participants were judged to be at lower risk of an emotional
disorder than those in the control group.
Barrett et al. (2003) also evaluated FRIENDS when delivered in urban Australian
schools with large populations of refugee and immigrant children and young people
from non-English speaking backgrounds. Findings suggest that the programme was
effective in increasing self-esteem and reducing anxiety and depression both
immediately after, and six months on, when compared to a waiting-list control group.
Stallard and colleagues (2007) have recently reported the preliminary findings of
their attempt to examine the effectiveness of delivering the FRIENDS programme in a
UK-school-setting. Using a previously-developed workbook, FRIENDS employs
groupwork, quizzes, role plays and other games to help children identify anxious
feelings and thoughts, and ways in which they might deal with these. The programme
was delivered to a whole class of Year Fives (children aged ten-11 years old) in one
urban and two more rural schools by two trained school nurses, who were supported
by the class teacher and any classroom assistants.
In all, 106 children aged nine to ten years old took part in FRIENDS. Children’s
self-esteem and anxiety levels were measured at three points in time – six months prior
to the commencement of the programme, at the beginning of the FRIENDS programme
and again three months after completion. While anxiety and self-esteem levels among
the children had remained stable in the six months prior to taking part in FRIENDS,
significant improvements were noted at three months after completing the
programmes. These significant improvements were also noted for those children for
whom anxiety and self-esteem levels pre-FRIENDS were of concern. While Stallard
et al. (2007) concluded that “further studies with larger cohorts using diagnostic
interviews are required to substantiate these findings” (p. 36), the strong evidence from
Australia combined with findings from this UK-based study suggest the FRIENDS Supporting
programme may be a promising universal approach to supporting children’s emotional children’s
wellbeing and mental health, specifically in relation to anxiety, depression and
self-esteem. wellbeing

Earlier assessment and support for children, young people and their families
Initiatives to help teachers identify children or young people requiring support for 279
emotional wellbeing and mental health formed the focus of some studies identified in
the literature review process (Cowling et al., 2005; Fealy and Story, 2006; Shortt et al.,
2006; Levitt et al., 2007). However, the quality of the methodologies employed meant
that none could be argued to offer evidence of a demonstrably effective or promising
approach. Instead the review threw up a number of evaluations focused on early
assessment and support initiatives based outside schools, which appear to offer a
reasonably promising evidence base of effectiveness.
Clemente et al. (2006) evaluated the Initial Assessment initiative (run by a range of
mental health professionals in London), which operated as a prioritisation system. Two
days a month were reserved by this mental health service to see newly referred families
(a maximum of 12 families a month). Before being seen by the clinical team, families
were required to assure the service they would do their best to attend their
appointment. Once families had met with a mental health professional for the first time,
a multi-disciplinary team meeting would discuss each case together to decide who the
most appropriate clinician would be to take on the work. Length of time families had to
wait between referral and first appointment, and rates of non-attendance at first
sessions for this initiative were compared to data from a similar CAMHS service in the
same area of London, which continued to operate a more traditional appointments
system.
Over a six-month period, 197 families were seen through the Initial Assessment
initiative. Compared to the control service where average waiting time between referral
and first appointment was twenty weeks, the service implementing the new initiative
only had an average waiting time of nine weeks. Non-attendance at first appointment
was also significantly lower when using the new triage system – ten per cent,
compared to 26 per cent at the comparison centre. The authors noted that there was no
difference in levels of eventual engagement between families accessing both services,
but that the Initial Assessment service offered a more efficient service by helping to
identify early on which families needed to be seen by the clinical team, and which did
not.
York et al. (2004) evaluated the STARTER (See To Assess, Review, Treat, Evaluate,
Review) clinics in operation since 2001 (after having been piloted for three months in
2000). Each clinic offered up to five appointments for new referrals a week, with a
further two urgent slots a month. All new referrals were offered a maximum of three
sessions. Over six months, 103 children and young people were seen by the STARTER
clinics. Waiting times for a first appointment were reduced by three-quarters from
eight months to eight weeks. One third of children and young people required three or
fewer sessions.
Heywood et al. (2003) evaluated a consultation and advisory service established
within a CAMHS team in a hospital. The service saw only non “complex and chronic”
(p. 506) cases, and families were offered one to three sessions within four weeks of
HE being referred. The evaluation found that waiting times and non-attendance were
108,4 reduced, only 24 per cent of families were actually referred on to CAMHS and parental
scores of the Strengths and Difficulties Questionnaire improved by 72 per cent
following contact with the service. Six months later, these positive changes had been
maintained and the research found that parental perceptions of their children’s
problems had changed – which was seen to be key in sustaining the change for
280 families.
Based on the results of a systematic review by Durlak and Wells (1998), it would
appear that early assessment and support programmes for children and young people
with emotional wellbeing and mental health problems would be well advised to adopt a
behavioural and cognitive-behavioural therapeutic (CBT) approach. After evaluating
130 initiatives, Durlak and Wells (1998) found that CBT appeared as effective as
psychotherapy for children with diagnosed mental disorders in early identification
initiatives. Furthermore, children and young people participating in behavioural or
CBT programmes recorded better outcomes than their peers in the control group by
approximately 70 per cent.

Working with parents – key to supporting children and young people with emotional
wellbeing and mental health problems
Three systematic reviews have examined whether working with parents and carers
can meet the needs of children and young people with emotional wellbeing and mental
health problems. Dretzke et al. (2005) looked at a number of studies to evaluate the
effectiveness and cost-effectiveness of CBT for parents of children with conduct
disorders. Overall, the results appeared to suggest that CBT can be an effective and
potentially cost-effective therapy for parents and children. However, the relative
effectiveness of different models of CBT was said to require further investigation.
Farmer et al. (2002) evaluated 21 controlled trials of non-residential treatments for
children with disruptive behavioural disorders or conduct disorders. The authors
limited their search to interventions which included children aged six to 12 years old.
Interventions could include children and young people, parent(s)/carer(s) or both.
Results indicated that parent training and community-based interventions may be
effective for children with conduct disorders.
However, Woolfenden and colleagues (2001) found less promising evidence when
evaluating the effectiveness of various family and parenting interventions. Eight
randomised controlled trials were identified, all of which had been conducted in the
USA. Analysis of the results found no consistent evidence of changes achieved in those
areas the programmes had set out to alter – children/young person’s behaviour, family
functioning, parenting approaches and parental mental health.
Despite Woolfenden et al.’s (2001) findings, results from a number of
methodologically robust individual evaluation studies support Farmer et al.’s (2002)
and Dretzke et al.’s (2005) research in suggesting that placing work with parents at the
heart of programmes aimed at supporting children and young people’s emotional
wellbeing and mental health is likely to be effective.
Such a suggestion is supported by Attride-Stirling et al.’s (2004) finding that
parental attitudes were key to understanding children and young people’s commitment
to a treatment programme. The authors found that parents whose children completed
their programme of treatment within CAMHS, when compared to parents whose
children had prematurely terminated their involvement, tended to be more focused on Supporting
their child’s difficulties, than broader family problems. children’s
Jarvis et al. (2004) evaluated the Parent Consultation Service at Open Door in
London – an initiative set up for parents whose children had failed or refused to wellbeing
engage in the psychotherapy service. A total of 26 parents received support from this
initiative in the time period studied and completed Problem Perception and the Stress
Index for Parents of Adolescents measure before and after the intervention. Parents 281
were offered between four and 39 appointments and scores on both measures were
found to have been reduced significantly. As Heywood et al. (2003) concluded, despite a
child or young person not engaging in a support service, if parental perceptions of the
issue and their interactions with their children could be changed, the difficulties
initially presented with can be reduced. No follow-up data were reported in this study.
Vostanis et al. (2006) reported on a programme where referrals to CAMHS in one
area of children aged under 12 years were initially dealt with by a team of family
support workers who aimed to work directly with parents in their homes, using Brief
Solution Focused Therapy and offering up to eight sessions of support. Using referrals
made to CAMHS in another locality as a comparison group, the researchers found that
parents receiving support from the team of family support workers were seen earlier
and improvements were noted in child emotional wellbeing and mental health
(measured using parent-completed Strengths and Difficulties Questionnaires and the
Health of the Nation Outcome Scales).
Kazdin and Whitley (2003) reported on findings from a US study whose results
supported the suggestion that very little extra work with parents was needed to have
an impact. A total of 127 families with children displaying aggressive behaviour were
offered a programme – where children received 20 to 25 cognitive behavioural therapy
sessions and parents attended up to 16 parent training session. One group of parents
received an extra intervention – five sessions on problem solving skills, and it was
those families who took part in this extra training who demonstrated the greatest
improvement.
One specific programme aimed at parents, widely disseminated in Australia, may
be of special interest to UK policy-makers and practitioners. The Triple P: Positive
Parenting Programme is designed for application in school settings. This programme
usually offers five levels of activities from a universal media and information
campaign, to brief consultation sessions, to more intensive individual and group parent
training or family-based interventions, dependent on level of need (for further
information visit: www.triplep.net/). While Triple P programmes are now being
delivered in various parts of the UK (Manchester and Glasgow for instance), no
published outcomes-focused evaluation studies of this work in the UK were identified
during the review.
In McTaggart and Sanders’ (2003) study of this programme, parents of children in
the first year across 25 primary schools in Melbourne were offered two sets of
activities – a media and information campaign, and group parent training. Data were
gathered from just under 500 children whose parents participated in the programme
(only a fifth of parents opted to take part in both elements, including the nine-hour
group training), with a similarly sized waiting list group. Based on teacher reports of
children’s classroom behaviour pre-, immediately post- and six-months after the
HE intervention, the authors concluded that the programme was able to prevent the
108,4 development of “conduct problems” (McTaggart and Sanders, 2003, p. 8) in children.
Ralph and Sanders (2003) undertook a smaller evaluation of this programme for
parents of 12 to 13 year-olds in a less urbanised area of Australia. A total of 27 parents
attended all eight group sessions run in the school library. Despite encouraging results
in relation to a reduction in parent-reported parent-teenager conflict, decreased scores
282 on laxness and overly-reactive parenting styles, and improvements in parental
self-efficacy, self-sufficiency, self-management, levels of depression, anxiety and stress,
the authors noted that encouraging parental participation and sustaining their
involvement over the whole course was a challenge.
Cann et al. (2003) reported on pre- and post- Triple-P programme data collected from
598 mothers of children aged less than one and up to 15 years old who either
participated in the group parenting element of the programme, intensive individual
support or the enhanced family-based intervention. Nearly half of the participating
parents’ children were assessed to have behavioural problems in the clinical range.
Post-intervention improvements were noted in the disruptive behaviour of children,
parental confidence, self-efficacy, stress, anxiety and depression levels, and reductions
in “dysfunctional parenting practices” (p. 7). Although the latter two studies are
weaker methodologically, the accumulation of evidence suggests that the Triple P
programme may well be a promising approach to improving child and parent
emotional wellbeing and mental health. Additionally, it may complement other
initiatives within schools which focus on children and young people directly.
Finally, it is worth noting that Harrington et al.’s (2000) controlled trial of parenting
education for parents of children with behavioural disorders in community-based
versus hospital-based services found no significant differences in the effectiveness and
cost-effectiveness of such initiatives by location. It is likely that developing schools –
and community-based programmes to support parents as well as those found in more
clinical environments would all contribute to improving outcomes for children and
young people.

Conclusion
This paper has aimed to make available to policy-makers and practitioners insights
from recent literature examining programmes to support children and young people’s
emotional wellbeing and mental health. While systematic reviews are often seen as
offering the only reliable basis on which programmatic decisions should be made, the
case has been made here that broadening the evidence base may be beneficial for two
main reasons.
First, systematic reviews do not include studies that could offer practitioners insight
into programmes that may offer promising approaches, as they have not yet been
evaluated according to criteria for inclusion in systematic reviews. In a rapidly
growing field (where funding often has to be committed in very short periods of time),
waiting for methodologically rigorous evaluations to be completed and reported is not
always feasible. Thus, reviews, which make accessible the information that is
available, while clearly outlining the limitations of study design, may have an
important role to play in supporting professionals to develop local and regional policies
and programmes (Rycroft-Malone et al., 2004). Second, this review has focused on
integrating evaluation findings from recent UK programmes, rather than relying too Supporting
extensively on research conducted in other contexts. children’s
The central aim of the review was to provide useful evidence to policy-makers and
professionals primarily in the UK, but also to be of interest to those working further wellbeing
afield. This influenced the methodology in two ways. First, we examined whether the
studies identified during the literature search could be easily grouped into a small
number of different programme types of relevance to the settings within which efforts 283
to promote and support children’s emotional wellbeing and mental health often take
place. This meant that the review focused on work in schools, early assessment and
support initiatives, and programmes working with parents.
Second, the research team prioritised the analysis of findings from methodologically
rigorous individual evaluation studies conducted within the UK, and sought to
integrate these with the conclusions of systematic reviews in the field of child
emotional wellbeing and mental health more generally. Studies from other countries
were only included in the review if they reported on programmes which had been
evaluated as effective and were linked to initiatives currently being trailed in the UK.
The research team had initially aimed to apply all three of the criteria developed to
define methodological rigour during the literature selection process. However, because
many studies were found to be methodologically weak (i.e. no control/waiting list
group was sampled; no follow-up outcomes data were gathered; and/or no
standardised emotional wellbeing and mental health measures were used), it was
decided to include studies, which met at least two of these three criteria. This was felt
to be justified because the review intended to build on the evidence base offered by
systematic reviews by analysing a broader range of studies than previously and by
including reference to “promising approaches” to promoting and supporting children’s
emotional wellbeing and mental health. The limitations of identified studies were
clearly indicated during the write-up.
In summary, review findings suggest that multi-component and universal
school-based programmes aimed at promoting emotional wellbeing and mental
health, sustained over a period of over one year, through the modification of the school
environment as well as the development of adaptive cognitive and behaviour strategies
among children and young people, offer evidence of an approach that is demonstrably
effective (Durlak and Wells, 1997; Wells et al. 2003; Green et al., 2005). There is also
evidence to recommend the combining of universal approaches with more targeted
behavioural and cognitive-behavioural therapy work with children and young people
who have identified emotional wellbeing and mental health needs (Durlak and Wells,
1998; Green et al., 2005). In relation to programmes for children and young people
experiencing emotional wellbeing and mental health problems within schools, the
FRIENDS programme (a CBT programme for children and young people with anxiety
difficulties) may be a promising initiative (Barrett et al., 2006; Stallard et al., 2007).
Early and brief intervention programmes, in the main delivered through CAMHS,
have been found to reduce waiting times for children and their families to receiving
much needed support (Heywood et al., 2003; York et al., 2004; Clemente et al., 2006),
reduce numbers who do not attend their initial appointment (especially if
parents/carers were asked to confirm they would attend before being placed on the
waiting list – Heywood et al., 2003), and increase the efficacy of CAMHS by reducing
HE the number of sessions a family requires (York et al., 2004) or ensuring referrals for
108,4 more specialist support were appropriate (Heywood et al., 2003; Clemente et al., 2006).
Finally, the review found that working with parents can not only substantially
complement work undertaken with children and young people (Farmer et al., 2002;
McTaggart and Sanders, 2003; Attride-Stirling et al., 2004), but importantly, it can form
a promising, stand-alone intervention by altering parental perceptions and improving
284 parents’ skills to cope with their children’s emotional wellbeing and mental health
needs (Heywood et al., 2003; Kazdin and Whitley, 2003; Jarvis et al., 2004; Vostanis et al.,
2006). Once more, using a CBT approach for work with parents/carers, especially if
they have children with conduct disorders appears effective (Farmer et al., 2002;
Dretzke et al., 2005).

References
Attride-Stirling, J., Davis, H., Farrell, L., Groark, C. and Day, C. (2004), “Factors influencing
parental engagement in a community child and adolescent mental health service:
a qualitative comparison of completers and non-completers”, Clinical Child Psychology and
Psychiatry, Vol. 9 No. 3, pp. 347-61.
Barrett, P.M., Somderegger, R. and Xenos, S. (2003), “Using FRIENDS to combat anxiety and
adjustment problems among young migrants to Australia: a national trial”, Clinical Child
Psychology and Psychiatry, Vol. 8 No. 2, pp. 241-60.
Barrett, P.M., Farrell, L.J., Ollendick, T.H. and Dadds, M. (2006), “Long-term outcomes of an
Australian universal prevention trial of anxiety and depression symptoms in children and
youth: an evaluation of the FRIENDS programme”, Journal of Clinical Child and Adolescent
Psychology, Vol. 35 No. 3, pp. 403-11.
Cann, W., Rogers, H. and Matthews, J. (2003), “Family Intervention Services program evaluation:
a brief report on initial outcomes for families”, Australian E-journal for the Advancement
of Mental Health, Vol. 2 No. 3.
Clemente, C., McGrath, R., Stevenson, C. and Barnes, J. (2006), “Evaluation of a waiting list
initiative in a child and adolescent mental health service”, Child and Adolescent Mental
Health, Vol. 11 No. 2, pp. 98-103.
Cowling, V., Costin, J. and Davidson-Tuck, R. (2005), “Responding to disruptive behaviour in
schools: collaboration and capacity building for early intervention”, Australian E-journal
for the Advancement of Mental Health, Vol. 4 No. 3.
Davis, C., Martin, G., Kosky, R. and O’Hanlon, A. (2000), Early Intervention in the Mental Health
of Young People – A Literature Review, The Australian Early Intervention Network for
Mental Health in Young People, Adelaide.
Department for Education and Skills (2003), Every Child Matters, Cm 5068, The Stationery Office,
London.
Department of Health (2004), CAMHS Standard, National Service Framework for Children,
Young People and Maternity Services, Department of Health, London.
Dretzke, J., Frew, E., Davenport, C., Barlow, J., Stewart-Brown, S., Sandercock, J., Bayliss, S.,
Raftery, J., Hyde, C. and Taylor, R. (2005), “The effectiveness and cost-effectiveness of
parent training/education programmes for the treatment of conduct disorder, including
oppositional defiant disorder, in children”, Health Technology Assessment, Vol. 9 No. 50,
p. 250.
Durlak, J.A. and Wells, A.M. (1997), “Primary prevention mental health programs for children Supporting
and adolescents: a meta-analytic review”, American Journal of Community Psychology,
Vol. 25 No. 2, pp. 115-52. children’s
Durlak, J.A. and Wells, A.M. (1998), “Evaluation of indicated preventative intervention wellbeing
(secondary prevention) mental health programs for children and adolescents”, American
Journal of Community Psychology, Vol. 26 No. 5, pp. 775-802.
Edwards, L. (2003), Promoting Young People’s Wellbeing: A Review of Research on Emotional 285
Health, SCRE Research Report 115, The SCRE Centre, University of Glasgow, Glasgow.
Evans, S.W. (1999), “Mental health services in schools: utilization, effectiveness, and consent”,
Clinical Psychology Review, Vol. 19 No. 2, pp. 165-78.
Farmer, E.M., Compton, S.N., Burns, B.J. and Robertson, E. (2002), “Review of the evidence base
for treatment of childhood psychopathology: externalizing disorders”, Journal of
Consulting and Clinical Psychology, Vol. 70 No. 6, pp. 1,267-302.
Fealy, S. and Story, I. (2006), “The mental health risk assessment and management process
(RAMP) for schools: I the model,”, Australian E-journal for the Advancement of Mental
Health, Vol. 5 No. 3.
Fonagy, P., Target, M., Cottrell, D., Phillips, J. and Kurtz, Z. (2002), What Works for Whom?
A Critical Review of Treatments for Children and Adolescents, The Guilford Press, New
York, NY.
Green, J., Howes, F., Waters, E., Maher, E. and Oberklaid, F. (2005), “Promoting the social and
emotional health of primary school-aged children: reviewing the evidence base for
school-based interventions”, International Journal of Mental Health Promotion, Vol. 7 No. 3,
pp. 30-6.
Harrington, R., Peters, S., Green, J., Byford, S., Woods, J. and McGowan, R. (2000), “Randomised
comparison of the effectiveness and cost of community and hospital based mental health
services for children with behavioural disorders”, British Medical Journal, Vol. 321
No. 7268, pp. 1,047-50.
Heywood, S., Stancombe, J., Street, E., Mittler, H., Dunn, C. and Kroll, L. (2003), “A brief
consultation and advisory approach for use in child and adolescent mental health services:
a pilot study”, Clinical Child Psychology and Psychiatry, Vol. 8 No. 4, pp. 503-12.
James, A., Soler, A. and Weatherall, R. (2005), “Cognitive behavioural therapy for anxiety
disorders in children and adolescents”, Cochrane Database of Systematic Reviews, No. 4.
Jarvis, C., Trevatt, D. and Drinkwater, D. (2004), “Parenting teenagers: setting up and evaluating
a therapeutic parent consultation service: work in progress”, Clinical Child Psychology and
Psychiatry, Vol. 9 No. 2, pp. 205-25.
Kazdin, A. and Whitley, M. (2003), “Treatment of parental stress to enhance therapeutic change
among children referred for aggressive and antisocial behaviour”, Journal of Consulting
and Clinical Psychology, Vol. 71 No. 3, pp. 504-15.
Levitt, J.M., Saka, N., Romanelli, L.H. and Hoagwood, K. (2007), “Early identification of mental
health problems in schools: the status of instrumentation”, Journal of School Psychology,
Vol. 45 No. 2, pp. 163-91.
McTaggart, P. and Sanders, M.R. (2003), “The transition to school project: results from the
classroom”, Australian E-journal for the Advancement of Mental Health, Vol. 2 No. 3,
pp. 1-21.
Mukoma, W. and Flisher, A.J. (2004), “Evaluations of health promoting schools: a review of nine
studies”, Health Promotion International, Vol. 19 No. 3, pp. 357-68.
HE Public Health Institute of Scotland (2003), “Needs assessment report on child and adolescent
mental health”, available at: www.phis.org.uk/pdf.pl?file ¼ pdf/CAMH%20final%20
108,4 report.pdf (accessed 17 October 2007).
Ralph, A. and Sanders, M.R. (2003), “Preliminary evaluation of the Group Teen Triple P Program
for parents of teenagers making the transition to high school”, Australian E-journal for the
Advancement of Mental Health, Vol. 2 No. 3, pp. 1-10.
286 Rones, M. and Hoagwood, K. (2000), “School based mental health services: a research review”,
Clinical Child and Family Psychological Review, Vol. 4, pp. 223-41.
Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A. and McCormack, B. (2004),
“What counts as evidence in evidence-based practice?”, Journal of Advanced Nursing,
Vol. 47 No. 1, pp. 81-90.
Shortt, A.L., Fealy, S. and Toumbourou, J.W. (2006), “The mental health Risk Assessment and
Management Process (RAMP) for schools: II process evaluation”, Australian E-journal for
the Advancement of Mental Health, Vol. 5 No. 3, pp. 1-12.
Stallard, P., Simpson, N., Anderson, S., Hibbert, S., Osborn and C. (2007), “The FRIENDS
emotional health programme: initial findings from a school-based project”, Child and
Adolescent Mental Health, Vol. 12 No. 1, pp. 32-7.
Topping, K.J. and Flynn, B. (2007), “Intervening with disturbed adolescents: a systematic
review”, manuscript submitted for publication, available at: www.dundee.ac.uk/eswce/
research/projects/ida/moreinfo/journalpaper/
Vostanis, P., Anderson, L. and Window, S. (2006), “Evaluation of a family support service:
short-term outcome”, Clinical Child Psychology and Psychiatry, Vol. 11 No. 4, pp. 513-28.
Wells, J., Barlow, J. and Stewart-Brown, S. (2003), “A systematic review of universal approaches
to mental health promotion in schools”, Health Education, Vol. 103 No. 4, pp. 197-220.
Wolpert, M., Fuggle, P., Cottrell, D., Fonagy, P., Phillips, J., Pilling, S., Stein, S. and Target, M.
(2006), Drawing on the Evidence – Advice for Mental Health Professionals Working with
Children and Adolescents, 2nd ed., CAMHS Evidence-Based Practice Unit, University
College London, London.
Woolfenden, S.R., Williams, K. and Peat, J. (2001), “Family and parenting interventions in
children and adolescents with conduct disorder and delinquency aged 10-17”, Cochrane
Database of Systematic Reviews, No. 2.
York, A., Anderson, Y. and Zwi, M. (2004), “Eight months to eight weeks: reducing waiting times
in a child and adolescent mental health service”, The Mental Health Review, Vol. 9 No. 2,
pp. 15-19.

Further reading
Appleby, L., Shribman, S. and Eisenstadt, N. (2006), “Promoting the mental health and
psychological wellbeing of children and young people”, Report on the Implementation of
Standard 9 of the National Service Framework for Children, Young People and Maternity
Services, Department of Health, London..

Corresponding author
Claire Maxwell can be contacted at: c.maxwell@ioe.ac.uk

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints