This submission details a quality improvement activity where the Child and Adolescent Mental Health Statewide Network (CAMHSNet) Clinical Nurse Specialist (CNS) at Coffs Harbour Health Campus has partnered with the local Child and Adolescent Mental Health Service (CAMHS) and Four local High schools to facilitate the Rock and Water Program. The Rock and Water Program (RWP) engages adolescent males in a fun, action oriented learning experience that aims to improve pro-social skills and reduce impulsivity, along with, reducing maladaptive expressions of anger. The project included educating local teachers and professionals to deliver the program.

To engage rural adolescent males in an anger management program that they perceive as useful and that leads to positive behavioural change that is noticed by parents, family and teachers.

An audit of referrals to the Coffs Harbour CAMHS for the years 1999-2003 demonstrated that 46% of males referred to the service identified anger or aggression as the main reason for the referral. Extensive informal discussions were held with a range of stakeholders who work with local youth via various meetings, forums and committees with a deficit identified in that there were no local evidence based programs available for adolescent males who express their anger in maladaptive ways, both covertly via substance abuse, suicidal ideation and high risk behaviour and overtly in the form of physical aggression. A subsequent literature review supported the implementation of the Rock and Water Program.

The Coffs Harbour CAMHS, during regular meetings that discuss clinician case loads, case-mix and client acuity, raised the issue that a large percentage of males referred to the team were related to anger and aggression. An audit of referrals was attended for the five year period 1999-2003 (inclusive) which established that 46% of males referred to CAMHS for a mental health assessment had identified anger or aggression as the presenting problem. Consultation with local professionals who work with youth via forums such as the school-link meeting, youth suicide committee, youth network meeting, DOCS/Health liaison meeting, agreed that there was a lack of evidence based local programs for adolescent males with anger and aggression problems.

A subsequent literature review was conducted to identify the important issues and current best practice relating to dealing with adolescent male anger and aggression. The RWP was identified as an innovative approach to working with adolescent males in the school context utilising a developmentally appropriate pedagogy, however, to date it had not been evaluated effectively.

During school-link meetings one school counsellor was particularly keen to initiate the RWP at her school and members of the CAMHS agreed that a large percentage of referrals for adolescent males had come from this school. The RWP was initiated with pre and post test data collected to evaluate whether or not the program demonstrated any positive behavioural changes in participants. Participants attended one 75 minute RWP session each week for eight weeks at their school. Initial results were encouraging, however, the qualitative data in the form of participant written comments and informal comments by participants, teachers and parents were overwhelmingly positive and were not captured by pre and post test quantitative data.

The literature review highlighted a void relating to adolescent perceptions of anger and aggression which was seen as being invaluable if programs were to be evaluated effectively and perceived by adolescents as useful and relevant to their everyday life experiences. Three further schools were selected via the CAMHS/school-link meeting due to them being outlying (out of the Coffs Harbour town area), as these schools received less CAMHS input and are possibly disadvantaged related to access.

To date 224 adolescent males have completed the RWP, a further 80 participants are currently attending the RWP. The groups, with ethics approval, are now contributing to the evaluation of the program content via focus groups where their contributions directly impact the quality improvement process.

Funding was sort via CAMHSNet for the CAMHSNet CNS to attend the RWP three day training so that a partnership with local schools could form to commence the RWP locally with adolescent males. Funding was also granted to attend the Advanced RWP Training, which meant that local professionals could be trained to deliver aspects of the RWP. The CAMHS manager supported two clinicians from the Innovative Health Service for Homeless Youth (IHSHY) to partner with the CAMHSNet CNS.

The RWP has been successfully implemented into four local high schools with approximately 224 participants completing an 8 week version of the RWP. As a component of the project 54 local professionals who work directly with youth have been trained, via a one day seminar, to deliver a large component of the RWP. All teachers from the participating schools have received a one hour presentation on the RWP which was included in their staff development program. A further 80 participants are currently providing qualitative data which will be used to evaluate and improve the RWP as necessary to meet participant needs and this process will continue throughout 2006 with a further 200 participants from five local high schools.

The pre and post-test data utilised a six point rating scale where Zero represented 'Not very Useful' through to Five which represented 'Very Useful'. 63% of Participants rated 5, Very Useful, 27% rated 4 and 10% rated 3.

Very similar results were demonstrated for whether or not Participants would recommend the RWP to other students with 58% of participants rating 5 'A great deal' and a further 22% rating 4.

Participants were asked to rate whether or not they had received any comments regarding positive changes to their behaviour since participating in the RWP from friends/ teachers or parents/family members and these results were also very encouraging as 43% of participants rated 3 or higher on a six point scale where 0 represented 'not at all' and 6 represented 'a great deal'.

Participants were provided a space for written comment and 40% of participants did write a comment which were overwhelmingly positive. As the project has continued to respond to participant need, ethics approval was sort and granted so that focus group data is now used to evaluate the program directly via participant input.

Fifty-four local professionals have attended a one day seminar to learn about the RWP with 99% of participants using the highest rating as per seminar evaluation, 'very satisfied' in all categories.

The four schools involved have had teachers trained to deliver the RWP and are building the program into their curriculum. In 2007 CAMHS will cease involvement as the schools will run the RWP in each of their settings. Findings from the current participant focus groups will be provided to each school and The Family Action Centre, (University of Newcastle) who facilitate the RWP training days State-wide, related to suggested changes / improvements to the program from the participants perspective.

The CAMHS will support schools to implement the RWP while also continuing to train teachers / local professionals to deliver the RWP. Results from this activity will add to the literature relating to engaging adolescent males who have problems with anger and aggression and will provide evaluation data regarding the effectiveness of the RWP in a rural context.

Manager, Clinical Governance Unit
North Coast Area Health Service
Phone: 02 6620 7225