 
Week 2 - Healthy School Communities
|  | Mutual Obligation - A Proposal for Lowering the Burden of Suffering from Emotional & Behavioural Problems in Our Society |
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Listing of Papers | |
MR GRAHAM SPEIGHT
Tasmania, Australia
'EVERYONE WANTS the children they love to experience healthy child development; to grow up to be healthy and competent children and adolescents; and to contribute to an innovative and competitive workforce leading to a prosperous society. This will result in social stability and, hopefully, resources will be available to fund and support programs that foster healthy child development.'
Dan Offord (1998, 2)
This is how Dan Offord introduced his session at the National Conference of the Australian Secondary Principals Association, in Hobart 1998. It was a session many of us found very thought-provoking. Offord's ideas have great significance for our work, particularly the way we support young people with emotional and behavioural problems.
In this short paper I present a synthesis of Offord's ideas. They can be summarised as a cycle of cumulative causation.
A major problem is that there is a growing 'casualty class of children'. These children are well-known to most of us: they suffer from early-onset emotional and behaviour problems and early school failure. As they proceed through their developmental years into adolescence, members of this casualty class are at increased risk of dropping out of school, and for illegal drug use and abuse. As adults, a sizeable proportion of them (upwards to half) are not fully functioning members of society.
By following the stages in Offord's cycle, it can be seen that the presence of the casualty class will reduce the extent to which the workforce can be innovative and competitive, and this will result in a less prosperous society (not least because we end up spending one in every five dollars of our Gross Domestic Product on social welfare).
These developments will increase the risk of social instability and make it less likely that resources will be freed up and available to support programs that foster healthy child development.
The cycle is therefore self-perpetuating. There needs to be an intervention to break it.
Changed Nature of the Casualty Class
The nature of the casualty class has changed. When I was a child the casualty class was made up of children with chronic medical illnesses. Morbidity from many of these illnesses has now disappeared: what now constitutes the casualty class are children with emotional and behavioural problems and their associated learning problems.
According to Offord, the size of the casualty class determines that interventions directed at individuals and their families are unlikely to significantly reduce its magnitude. What is needed are programs that improve the life quality and life chances of groups of children.
Fifteen years ago the only people interested in these issues would be those directly involved with the care of children. Now, however, all sectors of society are concerned with the problem of the casualty class of children. The business community understands that, unless the size of the casualty class is reduced, it will be difficult for their initiatives to thrive because of the lack of a well-trained and innovative work force.
Everyone understands that, to some degree, the casualty class will impact on their lives (through crime, vandalism and welfare costs, including the cost of maintaining prisons). The fact is that the current casualty class is of such magnitude that it will result in a reduced life quality, not just for the casualty class of children, but for all children.
Healthy Child Development Vital
It could be argued that, when there are tough economic times in a jurisdiction, the one type of program that should not be cut is one that fosters healthy child development. Offord argues that the best chance to lessen a recession, or to decrease an economic downturn, is to reduce the size of the casualty class.
Understanding the Problem
Acknowledging a problem is the first step in solving it. Once the problem is acknowledged, quantifying it is an important next step. Offord's research reveals that between 18 to 22 per cent of children between the age of 4 and 16, have clinically important levels of emotional and behavioural problems. Further, the children with these disorders not only have a lowered life quality because of the symptoms and associated impairments, but in many instances, the onset of these disorders heralds a lifetime of serious psycho-social difficulties. (A half of children with serious and persistent anti-social behaviour have marked psycho-social difficulties in adult life.)
If we accept that one in five of our children are thus affected, we can quickly move to the third step, and that is calculating the costs, both human and fiscal, of these conditions.
There is often a double jeopardy for these children because they so often live in poor communities. They suffer the double disadvantage of their impairment and being part of a poor community.
Children with one disorder are at increased risk for other disorders. Emotional and behavioural problems in children are not evenly distributed across the population. They 'pile up' in certain subgroups. This phenomenon leads to consideration of the definition of a 'marker'. A marker is usually an easily identifiable variable in a population, and indicates a population at increased risk for a condition or disorder, in this case emotional and/or behavioural problems.
There are two types of marker, those inside the child and those outside the child.
A strong marker inside the child is chronic medical illness (children with chronic medical illness have 2 to 4 times the rate of emotional and behavioural problems, compared to children without chronic medical illness). Markers outside the child include being the offspring of a single parent, being the offspring of a parent on social assistance and living in subsidised housing.
There are two major subgroups of conduct disorder:
- early onset; and,
- adolescent onset.
Early-onset conduct disorder has its antecedents in the preschool years. It is more common in boys, is associated with hyperactivity and learning problems, and the family background is frequently characterised by economic disadvantage and family dysfunction. It appears to have a poor prognosis.
Adolescent-onset conduct disorder, on the other hand, usually does not have childhood antecedents, is not more common in boys, and is not characterised by a family background of psycho-social disadvantage. It appears to have a better prognosis that the early-onset subtype.
Emerging evidence suggests that these two types of conduct disorder have different causes and will therefore require different types of interventions.
Interventions
Lowering the burden of suffering from emotional and behavioural problems cannot be accomplished by a single strategy. Universal, targeted and clinical programs are required in the context of a civic community.
Civic Communities
In his seminal work, 'Making Democracy Work: Civic Traditions in Modern Italy', Robert Putnam traces the development of civic communities that work.
A civic community is one in which there is civic engagement. Citizenship in a civic community is marked, first of all, by active participation in public affairs. There is solidarity, trust and tolerance among the citizens. Citizens are helpful and trustful of one another, even when they have differences on important matters. They set up community activities, such as athletic teams and choral societies, and there is a sense of collective responsibility for children in the community.
Social Capital
All children in a civic community have the right to full participation in community life. In civic communities parents take responsibility for more than their own children. Social cohesion and a high degree of collective effectiveness are characteristics of civic communities. Their willingness to intercede on behalf of the common good and strong horizontal ties in the community ensure that social capital will be present in impressive amounts. In a civic community we are obligated to the community, and the community is obligated to us. Defined in this way, mutual obligation is not about blaming victims but recognizing that we all 'take' from society and we all need to 'give', particularly to those with emotional and behavioural problems.
Intervention programs for emotional and behavioural problems will have little chance of success in the context of a disorganised civic community.
Universal Programs
In universal programs all residents in a geographic area (e.g., region, district, school) receive the intervention. The individuals do not seek help and no one is singled out for the intervention. Examples of universal programs in Tasmania would include parent training programs and the 'flying start' literacy program.
Although universal programs cannot be expected to have large effects on individuals, they may have a small effect on almost all members of the population, which translates into a large effect on the population as a whole. For example, if a universal intervention raises the IQ of each child by an average of five points, the gain for the individual child is small, but the total gain in IQ, from a population perspective, is immense.
Universal programs 'till the soil' for targeted programs. 'Tilling the soil' is important because where a universal program is in place in a setting such as a school or district, the milieu is one that is accustomed to the presence of the program, and then, if a targeted program is implemented, it is more likely to be widely embraced, and the identified children less likely to feel labelled or stigmatised.
Targeted Programs
In targeted programs, children are singled out for the intervention. The families and the children do not seek help. Children can be targeted in two ways:
- the marker can lie outside the child (child is the offspring of a parent on social assistance);
- the marker can be situated inside the child (anti-social behaviour).
Examples of targeted programs would include the MARSS program (a support model for 'at risk' adolescents) and individual educational plans (for students with learning difficulties).
The advantages of targeted programs can be summarised as follows:
- they are very efficient if the targeting can be done accurately;
- they present a human face - they can provide motivation for both the client and the provider;
- the intervention can be tailored to the individual;
- they can address problems early on.
The disadvantages of targeted programs are as follows:
- the procedure may be costly;
- the refusal rate of participation in the collection of screening data may be highest among those at greatest risk for future disorder;
- there is a boundary or threshold issue. At some point, a threshold is set on the basis of screening data. Many of the subjects will sit around the threshold and within this group the difference in risk of those who are targeted and those who are not may be slight;
- they tend to ignore causal factors (e.g., well-run day care centres);
- they focus on changing the behaviour of a high risk subgroup, which will be difficult if the behaviour at issue is widespread in the population (e.g., targeted programs with adolescents which place youths with behavioural problems together can intensify the problem and build peer relationships which promote deviant behaviour).
Clinical Programs
The major characteristic of this type of program is that the family with a child who is perceived to have a disorder seeks help. Examples include a specialised mental health or social service. The advantages are straightforward:
- they are easiest to sell to the public and politicians;
- they have a human face; and,
- they are efficient.
The disadvantages are mainly set around cost, but also include:
- inadequate coverage;
- difficulty with compliance (e.g., among families who begin treatment with mental health services, 50% terminate prematurely);
- labelling and stigmatisation;
- difficulty in assuming equal access, equal participation and equitable outcomes.
Clinical interventions should be aimed at reducing the deleterious effects of risk factors and increasing the beneficial effects of protective factors.
Strategy
The strategy is a sequence of interventions. There are four inter-related parts:
- the context of intervention should be a civic community;
- effective universal programs should be in place;
- targeted programs should follow for those not helped sufficiently by universal programs;
- for those unaffected by the targeted programs, clinical services should be available.
The advantages of such an approach are as follows:
- the number of people seeking (expensive) clinical services is reduced;
- there are multiplier effects;
- it supports the need to monitor the level of child psychiatric disorders on a population basis; and,
- one-step prevention programs are unrealistic.
Implications
We should accept that, over time, the mix of universal, targeted and clinical programs will change. This change will come as a result of increased knowledge and the impact of the interventions.
There will be trade-offs in any approach we adopt, but the 'cost' of continuing along the present path is too high.
Conclusion
Offord argues that most of what we do in providing support for young people with emotional and behavioural problems is (a) ineffective; and (b) unsustainable.
We need to create a better way of supporting those young people suffering from emotional and behavioural problems. It will require us to question our assumptions about existing programs and think differently about how we might structure our support services.
We currently have a range of services, which are characterised by fragmentation and duplication, situated in a range of host agencies.
Every principal can recount examples of 'case conferences' which have brought together an array of social workers, counsellors, health workers, probationers (I once counted 14) all servicing a single 'client' or family. The frustration associated with this waste of resources is often brought into sharp relief by the fact that once all this specialist knowledge has been synthesised, there are no resources to support the programs that are planned.
This is not to denigrate individuals or deny the professionalism and commitment of many of the professional people involved, but to acknowledge that it is time we tried another approach; something we can't do while the resources are 'tied up' in the old model.
Leadership and Political Will Required
A new approach would require us to free up resources that are currently posited in other agencies, it will require us to reconceptualise our provision of pre school services and the types of programs we provide for parents. It will mean a redirection of funds and services so that we resource the strategy. It will require leadership and political will.
What are the alternatives? Who can quantify the cost of failure? Who is prepared to support our current model? How can we create the coalition of interest, which will be needed to bring these changes about?
Clearly, the task of building civic communities and putting in place universal, targeted and clinical programs will take some time. In progressing down this pathway, there are two further insights from Offord worthy of our consideration.
The first is the importance of keeping score. This not only allows us to see where we've been, but will also furnish evidence about the effectiveness of the programs.
The second is philosophical and relates to how we conceptualise child development. Offord characterises it as a 'race'. His strategy seeks to:
- ensure that the race is fair; and,
- cut down the penalties for losing.
Currently, our approach is driven by the need to ensure that no one in the race has a legal comeback on the Government (through its various agencies) for its part in making the race unfair. I think we can do better than that.
Footnotes
Social capital denotes the strength of relationships among the people in a population. Physical capital has to do with buildings, machines and the like; human capital refers to the skills and attributes of the population.
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ABOUT THE AUTHOR
Mr Graham Speight is Principal of Launceston College, in Tasmania.
Graham Speight can be contacted by email at:
gspeight@launc.tased.edu.au |
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