Linking mental health indicators to promoting mental health in early life

Uploaded by NHSHealthScotland on 04.01.2012

Thanks very much and thanks for the opportunity to be here.
Most of you will know that I'm a sucker for any meeting involved with children's health.
I have come to the conclusion that the single most important thing we can do,
to improve the health of Scotland,
is to make sure that children get a good start in life.
Children's mental health is clearly an absolutely central element in what we're trying to do.
I think my reaction to the mental health indicators is how impressed I am with the depth.
Creation of health, creation of mental health, is a really complex business.
The temptation to come up with two or three things that are easy to collect,
and easy to measure and might measure processes,
and might get into a HEAT target or something like that...
obviously, that's very strong.
But at the end of the day, will it really tell us where we're going
about the determinants of children's health in general and mental health in particular?
I think the depth and complexity of the proposals are absolutely right.
We all agree, and I think everyone in Scotland recognises the importance
of social determinants of health,
and the complex relationships of what happens in society.
It's not true in all of these islands.
The further south you go, the more sceptics there are.
And the kind of thing I often hear when I talk about the importance of child health is,
"You don't have any evidence for that."
Well, you know,
evidence is one thing.
And I've got no doubt that with time, we will gather lots of evidence
about the way in which we are attempting to improve children's mental health.
But at the end of the day, I come down to the fact that -
we're not here necessarily and always to do things on the basis of evidence.
We're here to do things on the basis of what is right and just.
And looking after children properly,
we should do it because it's the right thing to do,
not because randomised controlled trials have told us it's the right thing to do.
With that kind of basic premise...
I'll just point out this diagram you will be very familiar with -
Göran Dahlgren and Margaret Whitehead's diagram,
showing the complexity of the various relationships
that all contribute to health and well-being,
starting off from the centre at the person
and going out to the broad socio-economic cultural and environmental context
in which they live.
I was sitting beside Margaret Whitehead at a meeting a couple of days ago.
She tells me this diagram is now copyrighted.
The problem is, she didn't copyright it, someone else has gone and copyrighted it.
It's an interesting bit of insight into the way academics work.
The point is,
it absolutely sets out the broad scale of influences on health.
I just want to run over some of the things that it would be really useful over the years
for us to find evidence about.
Things like children's mental health.
The percentage of children with a mental health disorder,
according to whether or not the parents are working:
both parents working, single parent working and neither parent working,
including workless single parents.
It doubles where employment is an issue.
And we can begin to see where we might be headed in the current economic climate,
over pressures on children's mental health.
Family type, on the left-hand side -
those are where there are two parents, married or cohabiting.
This is with lone-parent families,
increased risk associated with marital breakdown.
Weekly income - there's a stepwise decline
in the risk of mental health problems amongst children,
according to how wealthy a family is,
with under £100 a week income down here,
going up all the way to about £800 a week.
There's more than a doubling in the incidence of child mental health problems
associated with poverty.
Socio-economic classification.
Higher managerial classifications here,
never worked or long-term unemployed here.
Again, more than a doubling of problems where families are struggling economically to get by.
Educational qualifications adopts a similar pattern:
degree level up here, no educational qualifications down here.
So the importance of the way in which society works
is a huge driver of the mental well-being of children.
No matter what intervention services are doing,
and how we organise them and how effective they are,
at the end of the day, many, if not most of the drivers of the problems,
exist in the broader spectrum of things.
And that spills over into behaviours.
Where children have had an emotional behaviour,
they're far more likely to be current smokers,
to be regular drinkers and much more likely to have used drugs.
If you look at probably the most definitive study of the impact of adversity in childhood,
the ACE study - Adverse Childhood Events study -
which has been carried out in California...
It's not a hotbed of socio-economic deprivation.
And it was carried out between the Center for Disease Control in Atlanta
and the Kaiser Permanente Health System.
And Kaiser Permanente is an insurance system,
so the children in here will not have come from the poor end of the spectrum.
What they did was, they studied the impact of these nine types of adversity in childhood
on subsequent problems.
I'll just show you a few of them.
Children who experience four or more adversities in early life
are nearly eight times more likely to become alcoholics than children who experience none.
There is a molecular mechanism for that.
Adversity in early life changes the way certain genes are expressed,
that change the way certain centres of the brain work.
We know that these kind of adversities literally change,
go right to the heart of the cell and influence the way DNA is expressed.
Physical abuse -
boys who have experienced physical abuse in early childhood
are eight times more likely to beat up their girlfriends as teenagers,
three-and-a-half times more likely to have carried a weapon.
Domestic violence is a real problem for our society.
And you can do something about it
by dealing with the family conditions within which people live.
Teenage pregnancy - again, the more adverse events a girl experiences,
the more likely she is to have a teenage pregnancy.
It translates into physical ill-health as well.
None of these adverse experiences by themselves stick out as being particularly bad.
But they are cumulative.
The more you have, the higher the risk of all sorts of things happening.
This is heart disease.
The more adverse events you experience in childhood,
the more likely you are to experience heart disease in early life,
because of the stresses that it puts on the physiology.
The mechanisms, the underlying point about all of this...
The guy who really began to pull this together
was this sociologist, Aaron Antonovsky,
an American who spent the latter half of his career in Israel,
where he studied adults who as children had been in concentration camps.
He found, in talking to many of these adults in Israel,
that about 70% of them were very unhealthy - physically unhealthy and mentally unhealthy.
The question he asked himself was, "Why aren't they all unhealthy?"
If we experienced what they had experienced in early life,
it would have a very significant impact on the way in which you lived the rest of your life.
He looked at the 30% in great detail.
And he came up with a clear message
for the way in which we could create health for ourselves,
the way in which we could preserve our well-being,
and the way in which these children had managed to be resilient
in the face of serious, serious adversity.
What he said was that the 30% who remained healthy,
had acquired in early life what he termed a sense of coherence.
"A sense of coherence" consisted of three things.
It was the confidence that the children had,
that they could see the world as predictable and explainable and structured.
What was happening to them was bad,
but they could understand what was happening to them, after a fashion.
They could make sense of it,
in a way that allowed them to activate the resources that they had inside
to meet the challenges that they faced.
And finally, they saw those challenges as worthy of engaging, doing something with,
not lying down to.
Being able to see the world as a structured and explainable set of happenings outside you,
being able to be confident that you can meet most of the challenges that you face,
and wanting to meet those challenges and move on in your life,
protects children from physical and mental ill-health.
Antonovsky said that unless the social and physical environment was understandable,
manageable and meaningful,
we would experience a state of chronic stress.
It's that chronic stress that has all sorts of impacts that lead to physical, physiological,
anatomical and bio-chemical changes in individuals,
that make them at increased risk of mental ill-health and physical ill-health.
So what are we going to do about it?
Einstein said that insanity is keeping on doing the same thing and expecting different results.
And over the years, we've done many, many things
from the present paradigm of health improvement.
And health inequality has continued to widen, year on year.
Some things change marginally, some things improve.
We mustn't be negative about what we've managed to achieve.
But we need a step-change in what we're achieving.
This notion of assets for health is something I've been talking about.
I want to explain in a bit more detail exactly what I mean by that.
Because lots of people seize on the idea,
"Ah, yes, positive health rather than negative health,"
and carry on doing what they've always been doing.
If we embrace the idea of an assets approach,
it asks us really difficult and challenging questions about how we're working.
The idea of a health asset
is anything that is a property of us as individuals or our communities,
that allow us to sustain a sense of well-being,
protect us against the stresses that we experience in life.
Instead, the paradigm that we've got is that we focus on people's problems,
we talk about needs assessment,
we talk about the deficiencies that there are in communities,
we define people according to the problems they have.
And we design services to fix those problems.
As a result, people become passive recipients of our services,
when Antonovsky said the sense of being in control,
the sense of being able to manage our own lives,
was a positive health-producing phenomenon.
This notion that we do things to people rather than with them
is a key part of the assets approach.
I think if we're going to make life different for children in the coming years,
we need to do two things.
We need to support those parents who have got no experience
of attachment and nurturing with children.
We've got to help them understand the attachment process
and we've got to increase our sense of nurturing as a community.
The fact that we haven't signed up to a universal Declaration of the Rights of the Child, in the UK,
I think is an issue.
The fact that Scotland is seeking to do that is a very positive thing.
We've got an Early Years Change Fund.
It's not going to be a deal-breaker.
You know, it will be able to work at the margins.
But we've done that before, years ago,
when I was the lead cancer clinician.
We used a very small amount of money to radically change the way cancer services
were delivered, by doing different things with it
and encouraging people to move in a different direction.
So we've got an opportunity there
for increasing the nurturing atmosphere for children in Scotland.
The second thing we've got to do is we've got to tackle the broader agenda,
the broader social context
that the Dahlgren and Whitehead model talks about,
because it's no point living in sheer, grinding poverty
and having folk coming along and telling you to cuddle your children more.
Yeah, you'll cuddle your children more, but unless you do the broader things,
you're not going to radically change life's chances for those children.
So it's the second one of these things that the assets approach will help with.
Reconstruct communities by connecting people and activating assets.
So what is the assets approach? What do I understand by the assets approach?
How should we get going with it?
The first thing is, it's not new.
Lots of you in here will have heard of the Ottawa Declaration on Health Promotion.
25 years old, it is.
The Ottawa Declaration didn't call this the assets approach
but it actually described it in pretty good detail.
Process of enabling people to increase control over their health.
To reach a state of health.
To realise aspirations, satisfy needs
and to change or cope with their environment.
Health, therefore, is not seen as as resource for everyday life,
not the objective of living.
Health is just one of the many things we need to generate
in order to have a good life.
But we generate that health by increasing control over our life.
Health promotion works through effective community action,
helping people to plan strategies and implementing.
At the heart of the process is empowerment of communities.
It's a much over-used word.
It's over-used because although we've been talking about it for 20, 30 years,
we very rarely achieve it.
The ownership and control of their own endeavours and destinies.
We draw on the resources out there
to enhance self-help and social support.
Strengthen public participation.
It's all out there.
All the good words are out there and they've been out there for 25 years.
The time has come to really work through what it means applying it.
We've done a bit of it. We've done a bit of it successfully.
We have a coherent public health service in Scotland
and you're all members of it -
although you might not think you are,
but that's, in essence,
contributing to that sense of well-being in the community.
We all contribute to public health in that sense.
A couple of days ago, I was down in Westminster,
hearing about the proposals for public health in England.
And I say again, we have a coherent public health service in Scotland.
We've got great data-sets
and what we've heard about today will add significantly to that.
We've got very clever people to mind those data-sets
and give us the intelligence from them.
But the problem with implementing assets is their system.
Now, I don't mean by that that I'm about to go and pitch a tent in Blythswood Square,
or wherever it is, and join the anti-capitalist movement.
Although, you know...
I've got a lot of sympathy with them.
What would I mean by "the system"?
That's a system. OK?
It's a hierarchy.
And we're surrounded by systems.
Some of them are really good.
When I fly up from London, I want an aeroplane controlled by a pilot, not a committee.
Sometimes the hierarchical approach is really important.
But basically a system exists to allow a few people to control many people.
It exists to allow the production of a lot of the same thing.
Whether it be McDonald's hamburgers,
televisions, cars,
or whether it be services.
It allows a few people to control the way services are delivered to large populations.
And in order to function successfully as a system,
we need lots of consumers, or lots of clients.
So the prime function of a system is to create need.
And the problem with the deficits approach is it's driven by need.
And what we've got is a system that feeds off identified deficits out in the community.
That's what it looks like.
Individuals are surrounded by systems doing things to them.
Whether it be trying to sell you a hamburger, or trying to sell you a television set,
or trying to sell...
trying to define you as being in need of social services...
that's how it feels.
You're surrounded by people who want to control you.
Their purpose in life is to manage a complex net of other people
who will control how you live your life.
The guy who first identified, in political philosophy,
an alternative way of doing things,
is this guy.
A French count,
whose parents narrowly missed the guillotine,
who, not long after, in the early decades
of the 19th century, after the French Revolution,
went off to America and wrote a book called Democracy in America.
Democracy was a really new thing in political philosophy at the time
because Europe had been governed for millennia
by kings and noblemen,
by the aristocracy.
The French Revolution, feeding off, largely, the Scottish Enlightenment,
identified the meritocracy.
An interesting - and when I go down south, I always make this point -
that Rousseau, one of the philosophical architects of the French Revolution,
said, "We look to Scotland for all our ideas of civilisation."
Always like that one down there.
What de Tocqueville identified was
that America was dominated by associations of citizens.
They were, he gathered,
motivated by the pursuit of wealth.
And he was a very bright, insightful guy. A couple of things he said.
"The American republic will endure until the day Congress discovers
that it can bribe the public with the public's money."
And that quote goes on to say that once the money...
once they do that long enough and far enough, the money will run out.
The financial system will collapse and dictatorship will take over.
Another thing he said, relevant to where we find ourselves today, is this.
Democracies struggle with two things:
how to begin a war and how to end it.
A clever guy. Insightful guy.
Anyway, de Tocqueville said associations of citizens did three things.
They decided what their problems were,
they decided how to solve them,
and they organised to get on and fix it.
So what we've got, is on the one hand,
the idea that local communities should be organising.
The Ottawa Declaration said that was the prime way of generating health and well-being.
But, on the other hand, we've got an increasing trend
towards handing over more and more power, over our lives, to systems.
These associations were the founder, I think, of community development.
John McKnight has said
that associations provide care and mutual support,
respond to local problems,
produce individualised responses,
create innovation in society,
develop citizenship, et cetera.
And they create capacity in people.
Wouldn't that be good?
But yet the system will always fight back.
There is a struggle for power between the two ends of this spectrum.
First of all, you'll get outreach.
We will send people down to work with you.
i.e. we need to work harder to control you.
Partnership. You come and work with us and we will learn from you.
i.e. we will make you one of us and you'll stop being a pain in the neck.
Community consultation.
Come and tell us what you want and then we'll do what we think is right.
That struggle between the two ends of the spectrum.
And, you know, I'm not...
I am part of a system.
And we all are to a greater or lesser extent. And we all play these games.
But the challenge of the assets approach is to begin to think differently about it.
The balance is this.
People doing things that they can do
in order to enhance their life
in partnership with each other
and systems coming into play whenever they need to.
If you need a hip replacement, you want to be a client of a system.
Because Mrs McLaughlin up the road, no matter how nice she is,
ain't gonna replace your hip for you. OK?
But she might be able to help in all sorts of ways
around parenting, around play, around support in illness et cetera,
in a mutual basis.
So people doing what they can do for each other is important.
Services do not produce outcomes. People do.
It's not the Scottish government.
It's not the health board that produces the outcome.
It's the person who interacts in a positive way with the people they interface with that does it.
And that person has a choice about how they do it.
And McKnight also has said,
communities just aren't built on deficiencies.
They're built on mobilising capacity and assets of people and places.
So why is there a problem?
Why has the balance got out of kilter around this?
Systems have power,
and as employment, for example, declines, systems take over.
If you don't have money, you look to other folk to help you
and you're in the hands of the system.
But associations are more powerful than they think.
News today of a new bank being opened in Edinburgh
that guarantees not to run deficits,
not to borrow off markets and so on,
but to only invest in ethical investments
and make those investments utterly transparent.
That's an association. It's like credit unions and so on.
People organising to manage resources themselves.
Systems need customers and clients, so they have a vested interest in taking over.
Public health talks about needs assessment.
I can show you umpteen documents where communities are defined
on the basis of their unemployment rates, their criminality rates,
their heart disease rates and so on.
We define in our heads the problems that communities have.
The Raploch area of Stirling could be defined - and I'm sure it has been defined - that way.
But yet increasingly we're defining it
as a place where fantastic young musicians make terrific music.
The glass there is half full rather than half empty.
Said, this is when I get into jargon here.
I'm sorry about this slide.
But, basically, what we need to do
is we need to sit down and collaborate
around how we begin to share power.
And that means having people to collaborate with.
It means parents. It means local communities.
It means people who have lived miserable lives but who want to change those laws.
It means finding a vehicle for having a dialogue about the way forward.
And I've done this recently,
spent the last couple of years looking at organisations
and how they work, very closely.
One particular area in a lot of difficulty I went to see because it had a very specific difficulty.
In the course of the conversation I said to them, "What is your vision for this area?
What would you like it to look like?"
They all sort of looked at each other.
"Mm. Can we come back to you on that?"
About six weeks later, I got an email.
My jaw just dropped at the progress they'd made,
the networks that were beginning to accumulate around school, around businesses in the area,
around housing associations and so on,
and how people were beginning to talk to each other,
whereas before they were very nervous about each other.
Just asking the question starts the dialogue.
There then becomes an issue about supporting the local people
in finding their way around their system.
And learning how to use the various systems much more constructively
to support their development.
So that needs a bit of training and leadership evolves from that.
One of my heroines is a woman called Hazel Stuteley, a health visitor who,
down in a very deprived and...
a community really in trouble in the south of England,
started this process going many years.
And she got five local volunteers to sit down and discuss that question.
What vision do you have for the community?
And five years later, one of those volunteers was leader of the Council.
One was a government adviser on regeneration.
You know, these were just ordinary people, out of work, unemployed.
And about three others had started social enterprises.
So you never know what fires you light when you ask these questions.
But people will need support.
People will need to sit down and talk with others who have been through the same thing.
And, finally, there's the change bit.
How do you engage?
How did they reach out and engage the bits of their communities
that seemed resistant to engage?
The transformational change process.
The local proclamation of success.
The champions linking up with other people.
I've come to think of these people as connectors,
because fundamentally what they do is they connect people to each other.
That's the powerful bit of it all.
The Scottish Patient Safety Programme
has a process for this, a model for improvement,
asking the question - What do we want to achieve?
What is our vision for this community?
How do we know that we're going in the right direction?
Those are measures that might be defined locally.
What changes? How do we go about changing things?
Making small incremental changes.
And, then, finally,
there's the Act, Plan, Do, Study cycle
where folk are continually looking to see how they can refresh the process.
That's what happens at the local community level.
The challenge, though,
is for systems to let go.
Whenever I talk about the assets approach, people get -
some folk get very enthusiastic about it
and they translate that as me saying to them,
"Do what you do better.
And do what you do more intensively."
But the question I would ask people is -
Is what you do actually strangling the development of local communities?
If you deliver services on the basis of need,
can you take a step back
and let the local people begin to develop capacity
that will mean they no longer need your service?
And that's the challenge.
It's not about strangling communities even tighter.
It's about letting go.
So, this is not a new approach,
but our routine ways of working get in the way.
And we need to be more explicit in saying to communities,
"You're the boss. How can we help you? But you're very much in charge."
Some of the improvement science
that we've applied in the Scottish Patient Safety Programme may help with that.
But improving the assets that parents have to support children,
must be the priority,
because through doing that we will have an impact on all sorts of issues,
from criminality, to physical health in children and to a child's mental health.
Lao Tze, who is attributed as the founder of Taoism in China,
and who must have had a guy following him about with an iPad, or something like that,
because when you look up quotations, he's got thousands of them on the internet.
But this is a particularly appropriate one.
"Go to the people, live amongst them.
Start with what they have, build with them
and when the deed is done,
they will say, 'We have done it for ourselves.'"
That is real leadership.
That communities know they have done it for themselves,
that they're in control of their lives,
and not the system has done it for them.
When we get to that position,
I would predict that the incidence of things like child protection registrations,
child injuries,
adverse events like the ACE study, will have fallen away
and child mental health indicators will be on the up.
And I'll be the first across the border to tell colleagues down south.
Thanks very much.