Promotion of children’s mental health: nurses’ contributions

Abstract

Objective

To describe nursing intervention to promote children’s mental health.

Methods

This was an integrative review using PubMed, B-On, and CINAHL databases using the following keywords “health promotion”, “mental health, “child”, “nursing”, or “role of nursing” or “pediatric nursing” or “primary nursing care”, with combination of Boolean operators “AND” and “OR”. Full-text articles published in Portuguese and English within 10 years were included, after application of inclusion and exclusion criteria. A qualitative analysis with construction of three categories were included.

Results

We included 15 articles describing nursing interventions for children and adolescents at school, for family and community. The majority of interventions were approach at school with an emphasis on promotion of resilience and a healthy behavior.

Conclusion

The analyzed studies showed the importance of nurses to promote children’s mental health in mental health education programs, sensibilization and support to psychoaffective, biologic and social needs. A large variety of interventions organized and developed by nurses were observed at school, with families and as well as in the interrelationship with community.

Health promotion; Mental health; Child; Pediatric nursing; Primary health care

Resumo

Objetivo

Descrever as intervenções de enfermagem para a promoção da saúde mental das crianças.

Métodos

Revisão integrativa da literatura realizada nas bases de dados PubMed, B-On e CINAHL utilizando os descritores “promoção da saúde”, “saúde mental”, “criança”, “enfermagem” ou “papel do enfermeiro” ou “enfermagem pediátrica” ou “enfermagem de atenção primária”, com a combinação dos operadores booleanos “AND” e “OR”. Foram elegíveis artigos completos dos últimos 10 anos, nos idiomas português e inglês, coadunando aos critérios de inclusão e exclusão. Realizou-se análise qualitativa com a construção de três categorias.

Resultados

Incluíram-se quinze artigos que descreviam as intervenções de enfermagem com as crianças e adolescentes na escola, junto da família e com a comunidade, sendo que a maioria abordava as intervenções na escola com ênfase para a promoção da resiliência e comportamentos saudáveis.

Conclusão

Os estudos analisados evidenciam a importância dos enfermeiros na promoção da saúde mental das crianças em programas de educação em saúde mental, sensibilização e apoio às necessidades psicoafectivas, biológicas e sociais. Apresenta-se um leque de intervenções a serem organizadas e desenvolvidas pelos enfermeiros que trabalham na escola, com as famílias e em interligação com a comunidade.

Promoção da saúde; Saúde mental; Criança; Enfermagem pediátrica; Atenção primária à saúde

Resumen

Objetivo

Describir las intervenciones de enfermería para la promoción de la salud mental de los niños.

Métodos

Revisión integradora de la literatura realizada en las bases de datos PubMed, B-On y CINAHL utilizando los descriptores “promoción de la salud”, “salud mental”, “niño”, “enfermería” o “papel del enfermero” o “enfermería pediátrica” o “enfermería de atención primaria”, con la combinación de los operadores booleanos “AND” y “OR”. Se incluyeron artículos completos de los últimos 10 años en los idiomas portugués e inglés, junto con los criterios de inclusión y exclusión. Se realizó un análisis cualitativo con la construcción de tres categorías.

Resultados

Se incluyeron 15 artículos que describían las intervenciones de enfermería con niños y adolescentes en la escuela, junto con la familia y la comunidad, y la mayoría abordaba las intervenciones en la escuela con énfasis en la promoción de la resiliencia y comportamientos saludables.

Conclusión

Los estudios analizados demuestran la importancia de los enfermeros en la promoción de la salud mental de los niños en programas de educación en salud mental, sensibilización y apoyo a las necesidades psicoafectivas, biológicas y sociales. Se presenta un abanico de intervenciones que los enfermeros que trabajan en escuelas deben organizar y llevar a cabo, junto con las familias e interconectados con la comunidad.

Promoción de la salud; Salud mental; Niño; Enfermería pediátric; Atención primaria de salud

Introduction

Even more, a large number of children have experienced difficulties to repost to developmental challenges and they end-up suffering negative effects of mental disorders. Prevalence of mental disorders among children have increased within the last years and there are estimations that, currently, 10% to 20% of children have one or more mental health problems.( ¹ )In addition to those children with mental disorders diagnosis, there are others with behavioral problems and, although they case may be considered below the limits of clinical diagnosis, these children may present equal difficulties in terms of learning level, attention, psychomotor instability, and other related factors, as well as emotional suffering.( ² )

This reality requires an increase in response-ability and development of efficient forms to attend needs of these children and their families the early as possible. The National Mental Health Plan published in Portugal favors a set of strategies to prevent and promote mental health, such as mental health education programs for school age children, violence prevention and drug abuse, or programs focused on developing personal and social skills.( ³ )Health caregivers of the National Child and Youth Health Program, Health Action Plan for Children and Youth at risk are responsible to develop prevention strategies for those at risky situations, for minimizing occurrence of inadequate care, and/or for situations requiring special health needs. Nurses are part of each program and they have been recognized by the World Health Organization as leaders in health promotion strategies. In addition, nurses have contributed to improve knowledge and health literacy of population, which are understood as the ability to empower individuals to take informed health decisions by considering a number of related approaches that, together, contribute for development of environments, relations, feelings, and healthy and positive attitudes.( ⁴ , ⁵ )

It is well-known that nurses are often the closest professionals to schools and communities, and they are in unique position to help identify initial problems and provide early intervention to reduce psychosocial morbidities in children.( ⁶ , ⁷ )In the Portuguese National Health Plan nurses integrating the school health team when intervene in kindergarten, primary and secondary education, they end-up assuming an active role in health management of school community in terms of mental and emotional health, health education, physical activity, dental care, postural care, prevention of musculoskeletal problems, safety mobility, prevention of accidents, environmental and health education, promotion of affection and sexual education, prevention of tobacco use, alcohol consumption and use of other psychoactive substances, and also prevention of behavioral addiction (gambling, internet, and others).( ² , ⁸ )In the 2014/2015 report a higher investment was observed for students in the first cycle of primary education and for pre-school teachers.( ⁸ )To invest in health promotion at school is prioritize teachers by offering them adequate training on health-related factors that need to be integrated in school curricula of different disciplines. These knowledge should be transmitted to students using an adequate pedagogical approach and by considering school level of students. In the report, the massive investments in school health was to improve health literacy of students by given them more information related to environmental issues that may compromise health. However, school health also includes more specific aspects to promote and protect children’ physical and mental health, particularly for the crucial role of mental and physical well-being for academic development of a student.( ⁹ )School health nurses are reliable professionals and they are in privileged position to develop activities for health promotion and prevention, to recognize as early as possible signs in emotionally stressed children, and to provide care in a crisis situation.( ⁹ )

The Portuguese National Child and Youth Health Program focus on issues related with child development and includes as one of its main action the investment to prevent emotional and behavioral disorders.( ¹ )In children and youth periodic health surveillance, nurses assumes an important role( ¹ )to promote health, prevent diseases, identify early signs and interventions for children, adolescents, and their families at risk for psychosocial problems, provide follow-up, and support to them to overcome difficulties.( ⁵ , ⁶ )The support in terms of parents’ role constitutes a relevant focus in nursing care given that parents are the main caregivers and they assume the right and duty of educate their children and of become models for their children. Health promotion goes beyond a healthy life style, the guarantee of individuals’ global well-being, is not the exclusive responsible of health services. The mother, father or both, aligned with health professionals, must be committed in taking care to their healthy or sick child. There is believe that psychosomatic or psychiatric incidence is underestimated due to factors as inadequate identification of problems by primary health care professionals and even incorrect diagnosis of physical diseases which constitute psychosomatic or psychiatric symptoms.( ⁶ )Promotion of children’s mental health requires the intervention of several professionals, however, nurses have an important role at school, within families and in the community to whom focus must be directed for holistic dimension that includes biological, psychological, and social domains.( ¹⁰ )School nurses are professionals willing to promote mental health of children and their families who assume a social an professional contract and who are evolved with equity and justice.( ¹¹ )This study aims at describing nursing interventions to promote mental health of children. There is a need of systematize evidences about nursing interventions that consist of taking action to respond a nursing diagnosis to produce a nursing result.( ¹² )The nursing actions described in the analyzed studies included the following utterances: identify, encourage, promote, teach, support, advice, collaborate, and establish relationship. The objective of this paper is contribute to improve quality of nursing care in mental health care for children.

Methods

This integrative review was conducted using the following steps, identifying a topic, defining the research, establishing inclusion and exclusion criteria, identifying selected studies, evaluating included studies, analyzing and interpreting results and presenting a summary of knowledge review.(13) The review question was : “What are the nursing interventions to promote children’s mental health reported in published literature?” Data were collected from the National Library of Medicine and National Institutes of Health – PubMed, the B-On, and the Cumulative Index to Nursing and Allied Health Literature – CINAHL. Keywords used were obtained from the Medical Subject Headings (MeSH). Search was conducted by subject and the following search strategy was used: “health promotion” AND “mental health” AND “child” AND (“nursing” OR “nurse’s role” OR “pediatric nursing” OR “primary care nursing”). Two researchers searched and selected studies, independently. Inclusion criteria were: articles with nursing interventions to promote mental health of children published in Portuguese and/or English between 2009 and 2019. The 10 year period was chosen to allow a larger corpus of studies. To selected data, we followed the recommendations by Preferred Reporting Items for Systematic reviews and Meta-Analyses – PRISMA( ¹³ )( Figure 1 ) statement. Therefore, at the initial screening articles were selected based on their title and abstract, after full-text papers was read. Papers describing nursing intervention to promote mental health of children were included. Duplicated articles were analyzed only once.

Figure 1
Flowchart of identification, screening, eligibility and inclusion process adapted from PRISMA

Articles were analyzed considering established criteria. We included projects or investigations that presented nursing interventions for promotion of children’s mental health. Although this studies also presented results about adolescents, our interest was only in children. Level of evidence was classified as follow: Level I, systematic review or metanalysis; level II randomized controlled trials; level III non-randomized clinical trials, level IV cohort studies or well-designed case control, level V systematic review of qualitative and descriptive studies, level VI qualitative and descriptive studies, and level VII opinion of authorities and/or reports of experts.( ¹⁴ )After article reading we proceed to qualitative analysis and organization of data presented in results according to the following categories: nursing intervention at school, nursing intervention with the family, and nursing intervention in the community.

Results

Of the 15 included articles indexed in searched databases all were published in English.( ¹⁰ , ¹¹ , ¹⁵ - ²⁷ )Regarding the country where the study was conducted 6 were from the United States of America,( ¹⁰ , ¹¹ , ²⁰ , ²⁴ , ²⁵ , ²⁷ )6 from United Kingdom,( ¹⁵ - ¹⁸ , ²¹ , ²² )2 from Australia,( ¹⁹ , ²³ )and 1 from Canada.( ²⁶ )In relation to the year of publication, 1 study was published in 2009,( ¹⁵ )3 in 2010,( ²² - ²⁴ )1 in 2011,( ¹⁸ )1 in 2012,( ¹⁰ )1 in 2013,( ¹⁶ )2 in 2014,( ²¹ , ²⁷ )3 in 2015,( ¹¹ , ²⁰ , ²⁵ )2 in 2017,( ¹⁹ , ²⁶ )and 1 in 2018.( ¹⁷ )The LE of 3 articles was level V,( ¹⁰ , ²⁰ , ²⁷ )1 level VI( ¹⁵ ), and 11 level VII.( ¹¹ , ¹⁶ - ¹⁹ , ²¹ - ²⁶ )We observed that 13 studies were focused to schools( ¹⁰ , ¹¹ , ¹⁵ - ²⁵ ), and 7 were classified in more than 1 of the 3 identified categories ( Chart 1 ).( ¹⁰ , ¹¹ , ¹⁷ , ²¹ , ²³ , ²⁴ , ²⁶ )

Chart 1
Nursing interventions to promote children’s mental health and to be developed at school, with the family, and with the community. Classification of articles by level of evidence.

Nursing interventions at school	Level of evidence
Early detection mental health problems of children and adolescents, encouraging them to talk more about their feelings.	VI(15)VII(16,17)I
Promote development of emotional resilience of children and adolescents: Encouraging them to have a positive thinking, be optimist, embrace challenges, and make something to help others, to play and develop creativity, to promote self-esteem and self-efficacy, to develop good relationships and empathy between partners, and to explore opportunities for self-discovering, problem-solving, and learning with them in order to develop a sense of correctness and wrongness.	VI(15)VII(11,18,19)
Promote and encourage healthy eating, reduction of obesity, good night’s sleep and exercise regularly.	V(10,20)VII(17,18)
Promote health and emotional well-being by empowering participation within the community, improving the social inclusion and reducing the stigma associated with mental health problems.	VII(18,21)
Promote health and emotional well-being of all young men and boys, contributing for development of policies and sensible practices for difference needs based on gender.	VII(22)
Promote cognitive, historical, cultural, and experimental knowledge of students recognizing youth as knowledgeable, inviting them to share their option and test ideas in supportive environment.	VII(19)
Create opportunities for youths to be proactive and to guarantee mental health and well-being, amplifying their repertoire of positive skills that can generate solutions to face emotional and stressful situations.	V(10)VII(19)
Encourage youth to be unify as a group and establish ways to work together with teachers and community.	VII(19)
Involve them in activities in which they feel heard and valued, construct self-confidence, improve self-care and the care to others.	VII(17,19)
Promote an autogenic approach – well-being cultivation based on explorations of happiness and development of protective factors, not only to avoid risks.	VII(19)
Encourage them to leave their comfort zone with confidence to explore new areas. Empower students to develop internal locus of control and self-confidence to face challenges, and the will to consider new or divergent ideas, and to take responsibility to their own behavior.	VII(19)
Give support to healthy behaviors, safety and positive school environment, involvement with family and community at school.	V(20)VII(23)
Teach social-emotional skills for children and adolescents.	V(10)VII(24)
Encourage emotional well-being of youth based on cognitive-behavioral therapy: counseling about self-care strategies, help to increase exercise and to find social support, and also monitor the impact of changes in life style.	VI(15)
Provide short intervention for personal hygiene, dental care, healthy eating, life style, sleeping and routines.	VII(17,25)
Provide information, support and counseling to young people through social media such as Facebook or Twitter.	VII(17)
Nursing interventions with the family
Identify health and development problems of children (such as learning difficulties), safety (such as negligence of parents), and self-sufficiency economy of parents to provide help as earliest as possible.	VII(21)
Encourage good health and well-being throughout life, beginning in pregnancy, and including home visiting early in pregnancy up to two years of age, and planning of health needs.	VII(21,24,26)
Give support to parents during crisis and help them to establish a relationship and healthy environmental in which the children can growth.	VII(11)
Encourage mothers to breastfeeding.	VII(21)
Offer help parents to develop a strong bonding with children.(20)Support relationships between parents and children, and provide individualized approach for the need of each family.	VII(17,24,26)
Delivery person-centered care and directed for development of positive relations mother-baby.	VII(26)
Provide support to families’ needs to help them to create a more positive imaging of parents and environmental that they provide to raise and develop children.	VII(24)
Provide counseling of strategies to promote positive thinking among mothers to improve their own mental health and reduce risk of depressions and chronic stressors in order to avoid such impacts on children.	VII(24)
Provide protection for children with severe disease by screening and immunization.	VII(21)
Referral to health care of mothers, and children, families with low economic resources.	VII(21)
Educate parents to create a better life for their children and for themselves.	VII(26)
Nursing interventions in the community
Assess social inequalities and adequate interventions to promote health equity, developing partnerships with other sectors. Participation in the development of policies for inclusion of vulnerable groups.	VII(26)
Establish relationship with schools, assume an active leadership role by providing nursing support and management supervision.	VII(17,23)
Provide health support and well-being to mobile units: vaccination, education session for health about topics such as alcohol and smoking, healthy eating, physical exercise, and hand hygiene.	VII(17)
Home visiting and family education.	V(10)VII(24)
Recommendation for exposure to green areas – gardens, parks, forests, open spaces, therapeutic garden, encountering with nature, walks or runs.	V(27)

Discussion

Results of this integrative review were related with nursing intervention to the promotion of children’s mental health. Most common issues observed were psychoaffective problems, biological and social, education to promote health and well-being and, also to support and refer children and their family related to their needs. A limitation of this study was search in only 3 electronic databases, given that the variety of studies indexed in other databases. In addition, the studied period, the last 10 years, increased the possibility of retrieving the most recent data, however, this period limit was necessary to obtain a larger corpus of study.

As contribution for quality improvement of nursing care, this review brings supportive materials for nurses delivering care and promoting mental health of children. In this sense, the majority of articles reported schools as responsible to detect problems early,( ¹⁵ - ¹⁷ )promote well-being and reinforce the building of resilience throughout life, encourage development of good relationships and empathy among individuals,( ¹¹ , ¹⁵ , ¹⁸ , ¹⁹ )encourage the exploration of opportunities for self-discovering, resolution of problems, and how to learn with them.( ¹⁰ , ¹⁹ )There were also evidences of encouragement of children to involve with activities in which they feel heard and valued,( ¹⁷ , ¹⁹ )as well as teaching of social-emotional skills,( ¹⁰ , ²⁴ )provision of brief interventions to promote personal hygiene, dental care, healthy eating and life style, good emotional health, good night’s sleep and healthy routines.( ¹⁷ , ²⁵ )Schools give the opportunity to learn and practice healthy behaviors that can be managed by the school health services to create a safe and positive school environment, and promote involvement of families and school community,( ²⁰ , ²³ )which contributes to improve social inclusion.( ¹⁸ , ²¹ )For this reason, we highlight the importance of training nurses to be able to identify psychological suffering of children and adolescents, and to intervene adequately.( ²⁸ )

Early intervention is equally important for the family because mental health problems of children and adolescents are often related with childhood and pre-natal period. For this reason, a good health and well-being throughout life should be encouraged, and these behaviors should begin in pregnancy by periodic home visiting until two years of after birth and by planning families’ health care needs.( ²¹ , ²⁴ , ²⁶ )To promote children’s mental health there is need to help parents to develop a strong bonding with children and encourage care to keep children health and safe.( ²¹ )There is also the need to train parents to create a better life for their children and for themselves( ²⁶ ), and ways to support families of low economic resources.( ²¹ )In this sense interventions are encouraged in terms of promoting positive interpersonal relations among family members and the ability of families to perform basic functions favoring growth and development of children.( ²¹ )Therefore, nurses’ ability to work in partnership with parents must be recognized as an essential competence.( ²⁹ )Parents must be seen by nurses as partners in the child care, therefore, they should be trained by nurses to develop care competences, create strategies to reduce level of stress associated with parental role, and to promote and encourage self-autonomy of children.

The studies included in this integrative review revealed that community has a significant impact on mental health promotion of babies, children and adolescents’ on how nursing interventions reinforce participation in the community. Taking into considering cultural specificities of community, there is need to support strategies for mental health promotion of children, beginning by evaluation and reporting of inequalities and orientation for health equity through the partnership with other sectors.( ²⁶ )Other important nurse intervention consist of making home visiting, educate families,( ¹⁰ , ²⁴ )and provide support to health and well-being in mobile units( ¹⁷ )(a vehicle equipped to provide health care). Mental health considers how biological, psychological, and social circumstances can cross-interact throughout life by affecting health and disease trajectories, a fact that worth to intervene in children, using a planned and articulated manner for the future.

Conclusion

Given the high number and role of nursing interventions to promote emotional well-being, associated with good physical health, and general well-being and adolescents, we conclude that this article provides supportive materials to rethink and structure interventions to promote mental health at schools, as well as for families and community. We highlight the importance of psychoeducational interventions focused on teaching, counseling, incentive to adoption of healthy behavior, clarification of doubts to children, adolescents and parents, in addition to special attention to interactions with community in development of partnerships, home visits and outdoor activities. We observed that nurses have an essential role to detect problems, interrupt negative effects and developments, promote healthy behaviors and life styles, and improve social inclusion by strengthening community participation.

Acknowledgements

We thank European Social Fund, the Operational Program “CENTRO 2020”, and the Foundation of and Science and Technology of Portuguese Government for funding the research program MAISaúde Mental (More Mental Health) “Monitoring and assessing mental health indicators of children and adolescents: from research to practice” (identification number: CENTRO-01-0145-FEDER-023293) in which this study is included.

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Publication Dates

• Publication in this collection
  28 Aug 2020
• Date of issue
  2020

History

• Received
  02 Sept 2019
• Accepted
  20 Dec 2019