Mary Heald, Keeley French, Nicole Drake

Spring 2015
Introduction and Problem Statement
In the United States, the associated costs of mental disorders in citizens under 24 years of
age are estimated at $247 billion annually. As of 2015, four million American children and
adolescents suffer from a serious mental illness. Mental illness in children can cause many
strains on both the child and their family and even the government and societal infrastructure.
Children who suffer from mental disorders commonly have difficulty with blending into society,
whether that be in school, at home, or in another social environment and will frequently end up
involved in the juvenile justice system. Without the proper treatment and care for their disorders,
many children not only suffer from their disorder but also suffer from a decreased quality of life.
The first few years of life for a child are critical to predict a childs health and well being
and in many cases low to middle income families are not fulfilling their developmental potential
due to poverty and lack of stimulation. These socioeconomic challenges in the first few years of
life prevent children from reaching their full potential and predict lower IQ and academic
achievement, increased antisocial behavior, and poor health and chronic disease in adulthood.
According to the National Center for Children in Poverty, in the United States more than 16
million children, which totals more than 22% of all children in the country live in families below
the federal poverty level and more than 45% of all children live in low-income families
(Kataoka, 2009).
In a study conducted by the Center For Disease Control (CDC) from 1994 through 2011
it was found that 13% -22% of children living in the US will experience a mental disorder in a
given year. Through surveillance over the 17 year study the prevalence of these conditions was
seen to be increasing, meaning more children started developing disorders as the years go on
(Perou, 2013).
Children and youth who are at an increased risk for mental health problems include
children in low-income households, children in military families, and children protected by child
welfare services or the juvenile justice system. Twenty-one percent of low-income and youth
aged 6 to 17 suffer from mental problems while 50% of children in and adolescents in the child
welfare system experience mental health problems. An astounding 67% of youth involved in the
juvenile justice system have a diagnosable mental health disorder (Perou, 2013).
Children who are treated in the public mental health system are commonly involved in
multiple other social systems specifically for youths. These systems include juvenile justice,

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Spring 2015
child welfare, and frequently these children also need special attention within the school system
including special education. These children are also more frequently seen by doctors and incur
higher medical costs and can inadvertently become costly through decreased productivity. The
costs for these services are usually paid for by tax dollars and through government funding
which can be crippling if mental illnesses are at high levels within a community. Mental health
problems are the most expensive conditions for children, costing $8.9 billion per year compared
to the next most expensive condition, asthma, which costs $8.0 billion per year. Infectious
disease costs $2.6 billion a year, which is one-third the costs incurred by mental conditions in
children (Depression).
Besides the monetary costs of mental illness, there is also an emotional and social cost to
children suffering from a disorder. Children with mental health disorders are more likely than
their peers to experience difficulties in school including increased absenteeism, higher rates of
suspension and expulsion, lower test scores and overall grades and a greater risk of dropping out
of school during high school (Kataoka, 2009).
The goal of the intervention is to serve as a primary prevention tool to decrease the
prevalence of mental health disorders among the children who participate in the program. After
participating in the program children and their families living in low or middle income
households will have a better understanding of the physical, financial and emotional elements
that come with having a child with a mental illness. By increasing awareness of mental illness to
the younger population we hope to better the quality of life of community members already
diagnosed with an illness. The program would also guide participants towards resources
available within the community to assist them with family members caring for and treating either
themselves or their loved ones for possible mental disorders. Research has shown that by
creating support systems and educating children and families on the issues surrounding mental
health disorders the financial burden associated with maintenance of the disorders will decrease
(Foster, 2014).
The program is geared towards elementary aged children, enrolled in years kindergarten
through 5th grade, who come from areas of lower- middle income. In these socioeconomic areas
we would implement an after school program designed to integrate children with their
parents/families with the goal of teaching both parties about the prevalence of mental illness in
their community and communities similar to theirs. Most schools already have an after-school

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Spring 2015
program in place for students so the education program would be added in as an addition to the
already existing activities. Included in the program would be certified counselors and mental
health professionals, as well as the regular daily teachers to serve as familiar and comforting
confidants to the children.
As an incentive for participating in the program, caregivers will receive a discounted fee
for the after school program with the stipulation that the children and family members actively
participate in the activities and prevention program. This discounted fee can mean a great deal to
a lower income family and can save a lot of income to be spent on food or other necessities for
the child.
Literature Review
There has been significant research about the effects that living in low or middle income
communities have on a childs future, however very few current articles have explicitly focused
on the effects of early childhood education interventions on child behaviour and mental health
(Hoagwood, 2007). Furthermore, it was difficult to gauge how in depth the mediator analyses
were of the children/families, or if there were any, because each study was conducted within
different time frames, with different populations, and with different mediators. One study in
particular provided us with a cohesive introduction to early childhood education (ECE)
interventions and the different studies that have been successfully conducted that provide insight
into child mental health outcomes. This article titled, The Role of Early Childhood Education
Programmes in the Promotion of Child and Adolescent Mental Health in Low- and MiddleIncome Countries looked at 63 peer reviewed journal articles which looked at controlled
evaluations of ECE interventions. According to the results from these 63 studies, only 12 of 16
studies with short-term measures showed benefits, 6 studies included longer follow ups and all 6
found benefits. Some studies even included outcomes of caregivers/families. The researchers
came to the conclusion that child mental health will have a positive outcome from ECE
interventions if they include these three elements: activities to increase child skills including
cognition, language, self-regulation and social-emotional competence, secondly, training
caregivers in the skills required to provide a cognitively stimulating and emotionally supportive
environment; and lastly, attention to the caregivers mental health, motivation and self-efficacy.
One problem we found with this systematic review was the area that they conducted the studies.
The locations of the studies were countries such as Bangladesh, Lithuania, Bolivia, Jamaica,

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Spring 2015
South Africa and Bosnia (Hoagwood, 2007). Although these said places do provide valuable
insight to the struggles of low and middle-income families and children's mental health outcomes
in the United States, further studies should be conducted in America to further validate these
conclusions.
Another meta-analysis titled, Primary Prevention Mental Health Programs for Children
and Adolescents: A Meta-Analytic Review, compiles data concerning 177 primary prevention
programs that deal with youth social and behavioral issues (PP Meta Analysis 115). This analysis
draws conclusions based on qualitative and quantitative data and they claim that through
extensive research that, the average participant in a primary prevention program surpasses the
performance of between 59% to 82% of those in a control group, and outcomes reflect an 8% to
46% difference in success rates favoring prevention groups (PP Meta Analysis 115). The review
found that the definition of primary prevention has shifted in the programs throughout the past
years. Instead of solely focusing on the prevention of a specific mental illness, the programs
have sought to reduce behavioral and emotional issues and to promote mental health in hopes
that these efforts will, in turn, reduce the prevalence of mental health disorders in the future (PP
Meta Analysis 117). Parent training programs have not had great success in some cases, but the
success is found in programs that target early childhood and that offer support services in
conjunction with education and training (142). Based on this information our intervention
specifically targets young children and incorporates parents, but also aids them by taking care of
their children after school when they are not able to provide proper supervision. Many questions
remain in the field of mental health and because, the specific etiologies of behavioral and
psychological disorders are unknown and probably multiply determined, suggesting the need for
complex, multicomponent programs, (116).
Improved Intervention Strategy
For our intervention, we designed an after school program focused on lower income areas
in Manchester, New Hampshire. The program would be focused on elementary school children
(Kindergarten through 5th grade) whom are already in an after school program at their school.
The idea is that children who are already using an after school program service most likely have
parents who work a large amount of hours, which could be an indicator of a lower-income status,
as these extra hours of work are critical for their survival. This is a way of targeting a specific
demographic that is known to be more susceptible to developing mental health disorders in the

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Spring 2015
future. A program called, Breaking the Silence, which is a one day assembly where students,
health professionals, and educators, watch videos and participate in conversations about mental
health. If the faculty has already attended this assembly multiple times they will be
knowledgeable about the interactions and behaviors of health care professionals, patients,
caregivers, and students in real life situations and can apply those skills directly to the
elementary school children who are most at risk. In these areas we would implement a revamped
after school program designed to integrate children with their parents/families, which aims to
teach both parties about the prevalence of mental illness in low and middle-income communities.
Our hope is to create a more long-term sustainable program in regards to mental health. The after
school program, which would already be in place would be a balanced educational setting in
addition to a place to be active after school is out. The hope is to have counselors, mental health
professionals, and the teachers of the students as well as the parents and families of the children.
The program would continue to be a place where parents can count on the school to provide after
school care if they are at work or running errands, but is mainly focused on the interactions
between caregiver and child. The parents would not have to be present for every session and the
programs that are their attendance is critical to would be held towards the end of the after school
program, as we are still providing a service to help parents who cannot always watch their
children after school is out. Studies show that interventions which implement interactions
between parents and or caregivers and children are more effective at younger ages, which is one
reason that our intervention will be implemented in an elementary school. Exposure to
disadvantaged environments during the first few years of life predicts lower IQ and academic
achievement, increased antisocial behaviour, lower economic productivity and poor health and
chronic disease in adulthood, which is why implementing this after school program at such a
young age is critical (Hoagwood, 2007). The presence of the students teachers would provide
another way to monitor the progress of the students, being able to observe the children in an
academic setting as well as with their families in a non-academic setting provides crucial
information to the progress of the students and possible mental health outcomes in their future.
The mental health professionals and counselors would give an initial verbal assessment of the
children assessing their vulnerability to mental illnesses based on a handful of indicators(e.g.,
mood changes, behavior changes, intense feelings, difficulty concentrating, unexplained weight
loss, physical harm). The verbal assessments would continue at a monthly basis to monitor the

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Spring 2015
progress of the children as well as the program. The mental health professionals would also serve
as a reference point for parents and families who have questions. Since the new intervention
strategy is aimed at helping the community as a whole, we plan to invite community members
living with mental illness to serve as guest speakers and teach the children and their parents some
of their stories. In addition to sharing stories, they can serve as an additional point of reference to
other community members struggling with the many facets that encompass a mental illness.
Another aim of the intervention is to eradicate the negative stigma around people with mental
illnesses and increase awareness in not only the youth, but the rest of the community as well.
This integration of families, children, and community members with mental illnesses is aimed to
help create a more comprehensive, productive society. Because this intervention is community
based, on the socio-ecological model it would include the Intrapersonal level, the Interpersonal
level(including families, fellow teachers and students), and the Community, Institutions, and
Organizational structures (school setting and community interaction). In addition to the
wonderful opportunities given to theses lower and middle income families, the participating
children and parents will receive a discounted rate for being actively involved in the after school
program.
Challenges
The program is based in a low-income area of Manchester, NH, which could pose
problems with actively engaging parents in the after school program. As stated in the literature
review, the meta-analysis outlined the issues with getting parents involved and the effectiveness
of this strategy. It is our hope that the financial incentive will encourage parents to attend and
participate in the intervention, but there could still be issues with this. The definition of active
participation is loosely defined, as we do not expect the parents to attend every after school
meeting. We would like to leave it up to the discretion of the educators and administration, but
they may receive some backlash from parents who disagree with their judgment calls. If
necessary, a strict rule could be implemented regarding attendance, but we do not want to do this
originally, as we seek to be understanding of others priorities and responsibilities. It may also be
difficult to find individuals with mental health disorder who are willing and able to come to a
school with young children and discuss their struggles, which is an integral piece of our
intervention. There may also be issues with parents concerns about how appropriate the
intervention is for their young children, though they are not mandatory to attend. Although the

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Spring 2015
school has available funds for an educational program, there is a limit and this could pose
problems in the intervention. The health care professionals and the teachers would require
monetary compensation and depending on how long the sessions and how many of these
individuals participate could create a budget issue. The effectiveness of the intervention may be
negatively impacted if we were unable to implement it they way that we had planned it due to
lack of funding.
Evaluation
To measure the success of the intervention we aim to set up a monthly evaluation system.
We plan to have the students regular daily teachers and instructors present and helping to teach
the subject matter. Which will allow these teachers to make comparisons on how the students are
behaving before, during, and after participating in the program. Mental health professionals will
also conduct verbal assessments to the children asking questions associated with common risk
factors of mental illness. These verbal quizzes will determine if they are susceptible to
developing a disorder based on their lifestyle and behaviors and the lifestyle of their family
members.
Short-term outcomes of the intervention include increased awareness and knowledge of
mental illnesses, and eradicating negative stigmas. Another interim improvement would be the
cooperation between all parties involved including children, parents, teachers, and mental health
professionals. Medium-term indicators include improved behavior, and improved relationships
and interactions among the children.
The major long-term measurement of success of the program would be a decreased
prevalence of mental health disorders in youth and adolescents in the community. Another longterm effect would be the communitys better ability to cope with mental health disorders and
overall improvement in their quality of life. With the parents and students new knowledge on
disorders and possible treatment options, decreased numbers of students receiving disciplinary
action or being involved in the juvenile justice system would also be considered successful as
well as decreased absences because of illness symptoms. This would be observed through
tracking the students throughout middle school and high school and comparing disciplinary and
crime rates with rates of students who had gone through the school system before the program
was implemented.

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Spring 2015
If there are less mental health issues, there are less mental health treatment costs. There
are also lower costs incurred through crime and juvenile justice services. By making the
investment in education, the community would be savings large sums of money in the long run.
After the completion of the program we would give surveys to both parents and children asking
for feedback on what they found to be most helpful and what things they are still confused about.

Mary Heald, Keeley French, Nicole Drake

Spring 2015
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