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Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20
Violence and violence prevention: New roles for child and adolescent mental health practitioners Andrew Dawes
a b
& Cathy Ward
a
a
Department of Psychology , University of Cape Town , Private Bag X3, Rondebosch, 7701 b
Department of Social Policy and Intervention , University of Oxford , Barnett House, 22 Wellington Square, Oxford, OX1 2ER, United Kingdom Published online: 22 Aug 2011.
To cite this article: Andrew Dawes & Cathy Ward (2011) Violence and violence prevention: New roles for child and adolescent mental health practitioners, Journal of Child & Adolescent Mental Health, 23:1, 1-4, DOI: 10.2989/17280583.2011.594242 To link to this article: http://dx.doi.org/10.2989/17280583.2011.594242
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms
Downloaded by [University of Cambridge] at 13:07 08 October 2014
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Journal of Child and Adolescent Mental Health 2011, 23(1): 1–4 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1728–0583 EISSN 1728–0591 DOI: 10.2989/17280583.2011.594242
Commentary Violence and violence prevention: New roles for child and adolescent mental health practitioners
Downloaded by [University of Cambridge] at 13:07 08 October 2014
Andrew Dawes1,2* and Cathy Ward1 Department of Psychology, University of Cape Town, Private Bag X3, Rondebosch 7701 Department of Social Policy and Intervention, University of Oxford, Barnett House, 22 Wellington Square, Oxford OX1 2ER , United Kingdom *Corresponding author, email: [email protected] 1 2
Violence as a major public health problem for children The World Heath Organization defines violence as “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in, injury, death, psychological harm, maldevelopment or deprivation (WHO 1996).” South African children are no strangers to the many different forms of violence prevalent in the country. While we do not have epidemiological data on child maltreatment, the rate is likely to be very high (Dawes and Ward 2008, Richter and Dawes 2008). Youth victimisation surveys provide a picture of exposure to violent crime. For instance, a recent nationally representative survey of youth aged 12 to 22 years has established life-time prevalence exposure rates of 14% for assault, 10% for robbery (with a weapon) and between 3% and 4% for rape, with victimisation most commonly occurring in the home, at school, and in the neighbourhood streets (Centre for Justice and Crime Prevention 2009). Intimate partner violence, to which children may be exposed, is likely to affect at least 25% of South African households (Jewkes, Levin and Penn-Kekana 2002, Dawes et al. 2006). Similar rates are identified in other studies. A youth victimisation survey conducted by Leoschut and Burton (2006) found that 21.8% of young people between the ages of 12 and 22 years had witnessed violent disputes between members of their family. And in a survey of Eastern Cape men aged 15 to 26 years, Dunklea et al. (2006) found that close to a third of the sample (31.8%) had been sexually or physically violent to their main partner at some point in their lifetime. At least one of the risk factors for this violence lies in the domain of mental health, in the sense that violent conduct is supported by individual beliefs and local norms. In a major school-based survey of South African children, Andersson et al. (2004) found, most disturbingly, that 60% of boys and 62% of girls in the 10- to 14-year-old age group believe that “sexual violence does not include forcing sex with someone you know”. The costs of this victimisation are high. Using a database of 17 000 cases, the Adverse Childhood Experiences (ACE) study established that maltreatment, exposure to intimate partner violence (to the child’s mother) and living in a household where there was substance abuse and mental illness or an incarcerated family member, all contributed singly and (more commonly) in combination, to mental and other health problems in adulthood (Felitti et al. 1998). This study points to the heavy burden of disease (both physical and mental) created by child victimisation in the home. All forms of victimisation have of course been found to be associated with internalising and externalising disorders, and substance abuse (Ward et al. 2007). Clearly, in South Africa many children are Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
Downloaded by [University of Cambridge] at 13:07 08 October 2014
2
Dawes and Ward
at high risk of victimisation in intimate and more public settings, and the attitudes that support perpetration of violence (particularly against women) are widespread, even in the young. It would be unsurprising if a replication of the ACE study in South Africa were to turn up very similar results. The recent South African Stress and Health (SASH) study is suggestive. Adult survey participants who had adverse experiences in childhood (exposure to violence and maltreatment was not measured) were more likely than others to have mood (rather than anxiety) disorders (Seedat et al. 2009). Just as clearly as children are at high risk of victimisation, services are required at all levels from those provided to survivors to those aimed at primary and secondary prevention of exposure to violence. Currently, the supply of specialist public sector treatment services for children presenting with psychiatric disorders (including those consequent on violence exposure) is inadequate to meet the need (Lund et al. 2009). Unfortunately, there are no indications that this situation is likely to change any time soon, and while we need to strive for improved service access for the victims, we have to embrace interventions that are effective in preventing or at least reducing children’s exposure to violence. Additional impetus is added to this by the fact that the new Children’s Act obliges the state to support and fund prevention and early intervention services for child protection. Prevention services are outlined in Sections 143 and 144 of the Act, and, in terms of the Act, may be provided to families with children: “in order to strengthen and build their capacity and self-reliance to address problems that may or are bound to occur in the family environment which, if not attended to, may lead to statutory intervention (e.g. removal to care).” Preventive services could include the following, all of which would improve the protection of children and reduce the risk of maltreatment and violence exposure: 1. Efforts to strengthen parenting knowledge and capacities: carers are assisted to have a basic understanding of how children grow and develop so that their expectations are realistic — particularly in the case of infants and young children. 2. Efforts to link families and carers to the services they need when they need them, including for example, social security, antenatal and post-natal health services. 3. Services that can respond appropriately and early to family crises. 4. Training of educators, primary health clinic and early childhood development practitioners to detect early warning signs of family distress, and child maltreatment. 5. Enhancing community safety for children. 6. Introducing effective evidence-based school violence-prevention initiatives. Early intervention programmes in terms of the Children’s Act are intended to be provided to families where children are identified as being: “vulnerable to or at risk of harm or removal into alternative care.” This level of intervention focuses on families that are known to be at risk and include interventions designed to identify families with problems who need support, or who may be troubled by domestic violence, alcohol abuse and other social problems associated with adverse childhood experiences. As one of us noted in an earlier editorial in this journal (Dawes 2009): “For those in the field of child and adolescent mental health, both researchers and practitioners, the Act presents the challenge of developing an evidence-base for cost effective interventions to improve prevention and support for vulnerable families. It also presents training institutions with the opportunity to develop courses that equip practitioners for new roles.” Conclusions: What new roles could be imagined for the prevention of violence to children? The problem is huge. It occurs in multiple sites. Where to start? We would argue that two sites for intervention stand out because they enable us to reach large numbers of both adults and children. They are the family and the school. Families Much of the evidence points to the family as the site within which children are exposed to various forms of violence. Young children are particularly vulnerable in the years before school. Parents and other caregivers are key mediators of children’s development as well as being potential role models for effective non-violent forms of conflict resolution.
Downloaded by [University of Cambridge] at 13:07 08 October 2014
Journal of Child and Adolescent Mental Health 2011, 23(1): 1–4
3
Two recent reviews of child maltreatment prevention programmes both identify home visiting programmes (specifically the Nurse–Family partnership and Early Start programmes) as showing promise (MacMillan et al. 2008, Mikton and Butchart 2009), and one of these reviews also finds that parent education programmes, programmes that focussed specifically on “shaken baby syndrome”, and certain child sexual abuse prevention programmes also could be regarded as “promising” in terms of their evidence base (Mikton and Butchart 2009). In addition, Triple P, the Positive Parenting Programme developed in Australia as a population-based programme has a promising level of evidence for reducing child maltreatment (MacMillan et al. 2008, Prinz et al. 2009). The evidence does suggest that professionals are best at delivering these programmes. For instance, nurses have been found to be most effective in delivering good quality programmes in North American settings (Olds, Sadler and Kitzman 2007). However, this high level of professional intervention is not necessarily financially viable in lower income countries such as South Africa. Fortunately, recent evidence suggests that paraprofessionals can indeed be used effectively to deliver relatively complex interventions (Pence 2003, Kovach, Becker and Worley 2004, Rahman et al. 2008). These findings — that paraprofessionals can be effective under certain circumstances — offer hope in a situation where there is an insufficient supply of mental health professionals to engage in early and preventive interventions at the coalface. These professionals would be best employed in the training and supervision of others such as social auxiliary workers and lay persons. In fact, there are already local examples, such as the home visiting programme offered by the Parent Centre (www.theparentcentre.org.za) and the mental health intervention services offered by Empilweni (www.empilweni.org). We need to draw on indigenous resources rather than always assuming that professionals are best. Schools Schools are sites within which all children (with few exceptions) spend much of their lives. They offer significant opportunities for reaching the total school-age population. School-based interventions are very popular, but in fact the evidence-base for effectiveness is limited (this is particularly the case in South Africa). This is due on the one hand to methodological challenges in evaluations, and on the other to low programme dosage and poor implementation, both of which compromise otherwise promising interventions. Gevers and Flisher (in press) recommend a comprehensive whole-school approach to preventing violence in schools that pays attention to a range of areas including infrastructure (e.g. fencing and access control); training teachers for effective, positive classroom management skills; and training learners in conflict resolution skills. They refer to the Hlayiseka Project being implemented in certain Cape schools (Khan 2008). This programme provides a toolkit for school management that guides step-by-step school-wide changes to address violence and confidential systems for reporting incidents of violence. While the goal is for children to receive greater protection, learning outcomes are likely to improve as the classroom environment is more conducive to learning. While mental health specialists may play a role in the design and oversight of these interventions, it is educators who are most familiar with the school environment and who are key to successful implementation. These examples have implications for training public health oriented mental health professionals in the design, oversight, monitoring and delivery of evidence-based programmes to prevent child victimisation and promote positive family and school environments. As mental health professionals, we have skills that we can teach others, and so reach many more than we could if we followed a traditional model of in-office services delivered by one professional to one family or one child. References Andersson N, Ho-Foster A, Matthis J, Marokoane N, Mashiane V, Mhatre S et al. 2004. National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African pupils. British Medical Journal 329: 952, doi:10.1136/bmj.38226.617545.7C [On-line]. Centre for Justice and Crime Prevention. 2009. National Youth Lifestyle Study. Claremont, Cape Town: Centre
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for Justice and Crime Prevention. Dawes A. 2009. Editorial: The South African Children’s Act. Journal of Child and Adolescent Mental Health 21(2): iii–vi. Dawes A, Ward C. 2008. Levels, trends, and determinants of child maltreatment in the Western Cape Province. In: Marindo R, Groenewald C, Gaisie S (eds), The state of population in the Western Cape Province. Cape Town: HSRC Press. pp 97–125. Dawes A, de Sas Kropiwnicki Z, Kafaar Z, Richter L. 2006. Partner violence. In: Pillay U, Roberts B, Rule S (eds), South African social attitudes: changing times, diverse voices. Cape Town: HSRC Press. pp 225–251. Dunklea KL, Jewkes RK, Ndunad M, Levinc J, Jamab N, Khuzwayob N, Kosse MP, Duvvuryf N. 2006. Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS 20: 2107–2114. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP et al. 1998. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine14: 245–258. Gevers A. Flisher A. In press. School-based violence prevention initiatives. In: Ward C, van der Merwe A, Dawes A (eds), Youth violence in South Africa: sources and solutions. Cape Town: UCT Press. Jewkes R, Levin J, Penn-Kekana L. 2002. Risk factors for domestic violence: findings from a South African cross-sectional study. Social Science & Medicine 55: 1603–1617. Khan F. 2008. Building school safety: The Hlayiseka Project — A whole school approach. CJCP Issue Paper No. 6. Available at www.cjcp.org.za [accessed on 24 April 2008]. Kovach AC, Becker J, Worley H. 2004. The impact of community health workers on the self-determination, self-sufficiency, and decision-making ability of low-income women. Journal of Community Psychology 32: 343–356. Leoschut I, Burton P. 2006. How rich the rewards: results of the National Youth Victimisation Study. Cape Town: Hansa Press. Lund C, Boyce G, Flisher A, Kafaar Z, Dawes A. 2009. Scaling up child and adolescent mental health services in South Africa: human resource requirements and costs. Journal of Child Psychology and Psychiatry 50: 1121–1130. MacMillan H, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, Taussig HN. 2008. Interventions to prevent child maltreatment and associated impairment. Lancet, published online 3 December, DOI:10.1016/ S0140-6736(08)61708-0. Mikton C, Butchart A. 2009. Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organisation 87: 353–361. Olds DL, Sadler L, Kitzman H. 2007. Programs for parents of infants and toddlers: recent evidence from randomised trials. Journal of Child Psychology and Psychiatry 48: 355–391. Pence A. 2003. Thoughts on promoting capacity in support of child well-being. Child & Youth Care Forum 32: 313–318. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. 2009. Population-based prevention of child maltreatment: the U.S. Triple P system population trial. Prevention Science 10: 1–12. Rahman A, Malik A, Sikander S, Roberts C, Creed F. 2008. Cognitive behaviour therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a clusterrandomised controlled trial. Lancet 372: 902–909. Richter L, Dawes A. 2008. Child abuse in South Africa: Rights and wrongs. Child Abuse Review 17: 79–93. Seedat S, Stein DJ, Jackson PB, Heerings SG, Williams DR, Myer L. 2009. Life stress and mental health disorders in the South African Stress and Health Study. South African Medical Journal 99: 357–382. Ward CL, Martin E, Theron C, Distiller GB. 2007. Factors affecting resilience in children. South African Journal of Psychology 37: 165–87. WHO (World Health Organization). 1996. Global consultation on violence and health. Violence: a public health priority. Geneva: World Health Organization.
Journal of Child & Adolescent Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rcmh20
Violence and violence prevention: New roles for child and adolescent mental health practitioners Andrew Dawes
a b
& Cathy Ward
a
a
Department of Psychology , University of Cape Town , Private Bag X3, Rondebosch, 7701 b
Department of Social Policy and Intervention , University of Oxford , Barnett House, 22 Wellington Square, Oxford, OX1 2ER, United Kingdom Published online: 22 Aug 2011.
To cite this article: Andrew Dawes & Cathy Ward (2011) Violence and violence prevention: New roles for child and adolescent mental health practitioners, Journal of Child & Adolescent Mental Health, 23:1, 1-4, DOI: 10.2989/17280583.2011.594242 To link to this article: http://dx.doi.org/10.2989/17280583.2011.594242
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms
Downloaded by [University of Cambridge] at 13:07 08 October 2014
& Conditions of access and use can be found at http://www.tandfonline.com/page/ terms-and-conditions
Journal of Child and Adolescent Mental Health 2011, 23(1): 1–4 Printed in South Africa — All rights reserved
Copyright © NISC Pty Ltd
JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1728–0583 EISSN 1728–0591 DOI: 10.2989/17280583.2011.594242
Commentary Violence and violence prevention: New roles for child and adolescent mental health practitioners
Downloaded by [University of Cambridge] at 13:07 08 October 2014
Andrew Dawes1,2* and Cathy Ward1 Department of Psychology, University of Cape Town, Private Bag X3, Rondebosch 7701 Department of Social Policy and Intervention, University of Oxford, Barnett House, 22 Wellington Square, Oxford OX1 2ER , United Kingdom *Corresponding author, email: [email protected] 1 2
Violence as a major public health problem for children The World Heath Organization defines violence as “The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in, injury, death, psychological harm, maldevelopment or deprivation (WHO 1996).” South African children are no strangers to the many different forms of violence prevalent in the country. While we do not have epidemiological data on child maltreatment, the rate is likely to be very high (Dawes and Ward 2008, Richter and Dawes 2008). Youth victimisation surveys provide a picture of exposure to violent crime. For instance, a recent nationally representative survey of youth aged 12 to 22 years has established life-time prevalence exposure rates of 14% for assault, 10% for robbery (with a weapon) and between 3% and 4% for rape, with victimisation most commonly occurring in the home, at school, and in the neighbourhood streets (Centre for Justice and Crime Prevention 2009). Intimate partner violence, to which children may be exposed, is likely to affect at least 25% of South African households (Jewkes, Levin and Penn-Kekana 2002, Dawes et al. 2006). Similar rates are identified in other studies. A youth victimisation survey conducted by Leoschut and Burton (2006) found that 21.8% of young people between the ages of 12 and 22 years had witnessed violent disputes between members of their family. And in a survey of Eastern Cape men aged 15 to 26 years, Dunklea et al. (2006) found that close to a third of the sample (31.8%) had been sexually or physically violent to their main partner at some point in their lifetime. At least one of the risk factors for this violence lies in the domain of mental health, in the sense that violent conduct is supported by individual beliefs and local norms. In a major school-based survey of South African children, Andersson et al. (2004) found, most disturbingly, that 60% of boys and 62% of girls in the 10- to 14-year-old age group believe that “sexual violence does not include forcing sex with someone you know”. The costs of this victimisation are high. Using a database of 17 000 cases, the Adverse Childhood Experiences (ACE) study established that maltreatment, exposure to intimate partner violence (to the child’s mother) and living in a household where there was substance abuse and mental illness or an incarcerated family member, all contributed singly and (more commonly) in combination, to mental and other health problems in adulthood (Felitti et al. 1998). This study points to the heavy burden of disease (both physical and mental) created by child victimisation in the home. All forms of victimisation have of course been found to be associated with internalising and externalising disorders, and substance abuse (Ward et al. 2007). Clearly, in South Africa many children are Journal of Child & Adolescent Mental Health is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
Downloaded by [University of Cambridge] at 13:07 08 October 2014
2
Dawes and Ward
at high risk of victimisation in intimate and more public settings, and the attitudes that support perpetration of violence (particularly against women) are widespread, even in the young. It would be unsurprising if a replication of the ACE study in South Africa were to turn up very similar results. The recent South African Stress and Health (SASH) study is suggestive. Adult survey participants who had adverse experiences in childhood (exposure to violence and maltreatment was not measured) were more likely than others to have mood (rather than anxiety) disorders (Seedat et al. 2009). Just as clearly as children are at high risk of victimisation, services are required at all levels from those provided to survivors to those aimed at primary and secondary prevention of exposure to violence. Currently, the supply of specialist public sector treatment services for children presenting with psychiatric disorders (including those consequent on violence exposure) is inadequate to meet the need (Lund et al. 2009). Unfortunately, there are no indications that this situation is likely to change any time soon, and while we need to strive for improved service access for the victims, we have to embrace interventions that are effective in preventing or at least reducing children’s exposure to violence. Additional impetus is added to this by the fact that the new Children’s Act obliges the state to support and fund prevention and early intervention services for child protection. Prevention services are outlined in Sections 143 and 144 of the Act, and, in terms of the Act, may be provided to families with children: “in order to strengthen and build their capacity and self-reliance to address problems that may or are bound to occur in the family environment which, if not attended to, may lead to statutory intervention (e.g. removal to care).” Preventive services could include the following, all of which would improve the protection of children and reduce the risk of maltreatment and violence exposure: 1. Efforts to strengthen parenting knowledge and capacities: carers are assisted to have a basic understanding of how children grow and develop so that their expectations are realistic — particularly in the case of infants and young children. 2. Efforts to link families and carers to the services they need when they need them, including for example, social security, antenatal and post-natal health services. 3. Services that can respond appropriately and early to family crises. 4. Training of educators, primary health clinic and early childhood development practitioners to detect early warning signs of family distress, and child maltreatment. 5. Enhancing community safety for children. 6. Introducing effective evidence-based school violence-prevention initiatives. Early intervention programmes in terms of the Children’s Act are intended to be provided to families where children are identified as being: “vulnerable to or at risk of harm or removal into alternative care.” This level of intervention focuses on families that are known to be at risk and include interventions designed to identify families with problems who need support, or who may be troubled by domestic violence, alcohol abuse and other social problems associated with adverse childhood experiences. As one of us noted in an earlier editorial in this journal (Dawes 2009): “For those in the field of child and adolescent mental health, both researchers and practitioners, the Act presents the challenge of developing an evidence-base for cost effective interventions to improve prevention and support for vulnerable families. It also presents training institutions with the opportunity to develop courses that equip practitioners for new roles.” Conclusions: What new roles could be imagined for the prevention of violence to children? The problem is huge. It occurs in multiple sites. Where to start? We would argue that two sites for intervention stand out because they enable us to reach large numbers of both adults and children. They are the family and the school. Families Much of the evidence points to the family as the site within which children are exposed to various forms of violence. Young children are particularly vulnerable in the years before school. Parents and other caregivers are key mediators of children’s development as well as being potential role models for effective non-violent forms of conflict resolution.
Downloaded by [University of Cambridge] at 13:07 08 October 2014
Journal of Child and Adolescent Mental Health 2011, 23(1): 1–4
3
Two recent reviews of child maltreatment prevention programmes both identify home visiting programmes (specifically the Nurse–Family partnership and Early Start programmes) as showing promise (MacMillan et al. 2008, Mikton and Butchart 2009), and one of these reviews also finds that parent education programmes, programmes that focussed specifically on “shaken baby syndrome”, and certain child sexual abuse prevention programmes also could be regarded as “promising” in terms of their evidence base (Mikton and Butchart 2009). In addition, Triple P, the Positive Parenting Programme developed in Australia as a population-based programme has a promising level of evidence for reducing child maltreatment (MacMillan et al. 2008, Prinz et al. 2009). The evidence does suggest that professionals are best at delivering these programmes. For instance, nurses have been found to be most effective in delivering good quality programmes in North American settings (Olds, Sadler and Kitzman 2007). However, this high level of professional intervention is not necessarily financially viable in lower income countries such as South Africa. Fortunately, recent evidence suggests that paraprofessionals can indeed be used effectively to deliver relatively complex interventions (Pence 2003, Kovach, Becker and Worley 2004, Rahman et al. 2008). These findings — that paraprofessionals can be effective under certain circumstances — offer hope in a situation where there is an insufficient supply of mental health professionals to engage in early and preventive interventions at the coalface. These professionals would be best employed in the training and supervision of others such as social auxiliary workers and lay persons. In fact, there are already local examples, such as the home visiting programme offered by the Parent Centre (www.theparentcentre.org.za) and the mental health intervention services offered by Empilweni (www.empilweni.org). We need to draw on indigenous resources rather than always assuming that professionals are best. Schools Schools are sites within which all children (with few exceptions) spend much of their lives. They offer significant opportunities for reaching the total school-age population. School-based interventions are very popular, but in fact the evidence-base for effectiveness is limited (this is particularly the case in South Africa). This is due on the one hand to methodological challenges in evaluations, and on the other to low programme dosage and poor implementation, both of which compromise otherwise promising interventions. Gevers and Flisher (in press) recommend a comprehensive whole-school approach to preventing violence in schools that pays attention to a range of areas including infrastructure (e.g. fencing and access control); training teachers for effective, positive classroom management skills; and training learners in conflict resolution skills. They refer to the Hlayiseka Project being implemented in certain Cape schools (Khan 2008). This programme provides a toolkit for school management that guides step-by-step school-wide changes to address violence and confidential systems for reporting incidents of violence. While the goal is for children to receive greater protection, learning outcomes are likely to improve as the classroom environment is more conducive to learning. While mental health specialists may play a role in the design and oversight of these interventions, it is educators who are most familiar with the school environment and who are key to successful implementation. These examples have implications for training public health oriented mental health professionals in the design, oversight, monitoring and delivery of evidence-based programmes to prevent child victimisation and promote positive family and school environments. As mental health professionals, we have skills that we can teach others, and so reach many more than we could if we followed a traditional model of in-office services delivered by one professional to one family or one child. References Andersson N, Ho-Foster A, Matthis J, Marokoane N, Mashiane V, Mhatre S et al. 2004. National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African pupils. British Medical Journal 329: 952, doi:10.1136/bmj.38226.617545.7C [On-line]. Centre for Justice and Crime Prevention. 2009. National Youth Lifestyle Study. Claremont, Cape Town: Centre
Downloaded by [University of Cambridge] at 13:07 08 October 2014
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