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 Table of Contents  
DEBATE/PERSPECTIVE/VIEWPOINT
Year : 2017  |  Volume : 33  |  Issue : 2  |  Page : 118-122

Preventive strategies in child and adolescent psychiatry


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication30-Jun-2017

Correspondence Address:
Rajesh Sagar
AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_43_17

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  Abstract 

Childhood and adolescence are periods of growth and development that are critical to the formation of adult personality and psychopathology. Moreover, childhood psychopathology may differ significantly in presentation and risk factors from those seen among adults and may require different preventive strategies. Service-related characteristics such as the shortage of trained child and adolescent mental health professionals also demand that the focus should shift from resource-intensive treatment interventions, toward preventive measures that can be delivered at lower cost in terms of workforce, money, and time; and can lead to improved outcomes for a wide variety of conditions. Preventive strategies that have been implemented in this population have mostly included both preventive measures (aiming at reducing the prevalence of risk factors) and promotive components (aimed at increasing resilience and positive mental health characteristics), usually in combination. Interventions have been shown to be most effective when they are targeted at underlying latent structures that predict risk; they are also more effective when delivered over a prolonged period. Interventions must also be formulated such that they are developmentally appropriate, and with clearly stated outcome parameters for evaluation. A few example interventions that have made use of these strategies are discussed in the course of this article.

Keywords: Adolescent psychiatry, child psychiatry, preventive strategies


How to cite this article:
Sagar R, Krishnan V. Preventive strategies in child and adolescent psychiatry. Indian J Soc Psychiatry 2017;33:118-22

How to cite this URL:
Sagar R, Krishnan V. Preventive strategies in child and adolescent psychiatry. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Nov 13];33:118-22. Available from: http://www.indjsp.org/text.asp?2017/33/2/118/209192


  Introduction Top


Current preventive approaches for mental health are based on a particular understanding of mental illness and its development. First, mental illnesses are understood to occur due to the combined effects of a number of physiological, psychological, and environmental variables. Some of these factors (such as parental loss, early substance use, and even genetic factors) have been implicated in the causation of more than one mental illness, and thus it may be the specific combination of factors (both inborn and acquired) that leads to the observed phenotype.

The effects of risk factors may be of various kinds. In the simplest mode of effect, the presence of one characteristic may fully predict the presence or absence of mental disorder, for example, the association between trisomy 22 and the phenotypic manifestations of Down Syndrome. However, in most cases, the effect of a risk factor is to either contribute some measurable vulnerability to the causation of illness; to delay or hasten the onset of illness; or to contribute to a specific symptom profile. For a majority of risk factors, the manifestation of mental illness does not follow immediately after the risk factor, or effects may be due to repeated experience rather than a single occurrence.

A practical classification of various risk and protective factors is provided in [Table 1].[1] As can be seen, these factors may be located either within the individual, in the interpersonal space, or in the broader societal milieu.[2] Preventive measures must, therefore, take these contextual factors into account, as they may be more important for prevention than individual factors; the interventions might also be more broadly classified as educational, social or political, rather than strictly medical in nature.
Table 1: Classification of risk factors and protective factors

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Preventive measures may also have differing objectives. Certain measures could be specifically directed toward the reduction of risk factors such as interventions to reduce child neglect or abuse, school dropout, or delinquency. Others may be aimed at promoting positive characteristics that can increase persons' resilience to a number of mental illnesses, for example, teaching coping skills and improving resilience to adversity. Preventive interventions may be narrowly focused on a single target, but are more often structured as a package of interventions delivered together, which include both preventive and promotive elements.

Another issue for implementation of the preventive program is in their appraisal. Here, two issues need to be addressed. First, intervention targets and outcomes tend to overlap, and it may be difficult to tease out the specific effects of a single intervention on any single target. As may be expected, this becomes, even more, the case while discussing multi-component interventions. Second, intervention outcomes must include assessments of functioning in various domains and at various time-points, or proxy markers such as academic achievement, employment and wages, or relationship markers. A further consideration is that disorders that affect a person during the developmental period may have a variable natural course: some disorders remain stable others either worsen or improve over time. Thus, intervention effectiveness can only be judged by comparison with a control group that is developmentally similar to the case group.


  Current Scenario for Preventive Psychiatry Top


Preventive mental health interventions are coming into focus partly due to their potential to reduce the burden due to mental illness. By and large, preventive services are cheaper than treatment-interventions while considering per capita costs to the target population. They also require less expertise, and the same intervention can be delivered to large numbers, i.e. they can be deployed very quickly, which is not easy for interventions that are focused on treatment. However, despite these findings, it has been shown repeatedly that clinicians provide fewer preventive interventions than those recommended by professional guidelines,[3],[4],[5] and the reasons for this may relate to environmental constraints (e.g., lack of time), clinician-related characteristics (e.g., training or attitude), or patient-related characteristics (e.g., perceived need for preventive intervention).[6]


  The Developmental Importance of Childhood and Adolescence Top


The period from birth until adolescence is critical for preventive psychiatry. First, mental morbidity is one of the largest contributors to disability within this period. The WHO report estimated that 20% of children and adolescents suffer from a disabling mental illness.[7] Suicide is the third leading cause of death among adolescents.[8] Apart from these effects, that are directly related to psychological health, the impact of mental illness in this can also be measured on a number of other parameters, such as academic performance and interpersonal adjustment, criminality, and marital problems.[9]

The period of childhood and adolescence is particularly important when interventions are planned to prevent mental illness and promote mental health. This is because effective intervention in this period could lead to better outcomes not just in the immediate future, but also alter developmental trajectories and later-life functional outcomes. For example, Kessler et al.[10] have shown that 50% of psychiatric illnesses have an onset before the age of 14 (with another quarter of cases being added by the time individuals turn 25).


  Preventive Interventions Top


Conventionally, preventive psychiatry interventions were classified depending on the stage of illness that was being addressed.[11] Primary prevention is directed at those without illness and aimed to prevent the onset of illness. Secondary prevention measures are those aimed at individuals with latent or asymptomatic forms of the illness, aiming at preventing overt manifestations and curtailing the duration spent in illness. Tertiary prevention is aimed at those with established illness, in whom the target is a reduction of complications and disability. In this framework, both public health interventions and clinical treatment are included as preventive measures.

More recently, the Institute of Medicine has restricted the classification of preventive medicine to populations without illness, i.e., those measures that would have been considered to be primary prevention measures.[12] These may be further classified depending on the target population as universal measures, targeted interventions, or indicated interventions. These are described in [Table 2]. In general, more complex interventions (that depend on professional expertise or which can only be delivered in a cost-effective manner when the population for intervention is selected, and the effectiveness of interventions that are delivered to the general population can only be measured when the effect size is large. Multi-stage preventive interventions may be considered, in which risk stratification may be followed by differentiated interventions for individuals in each risk group. Such an intervention strategy may be particularly effective for mental disorders with a low base rate, as appraisal becomes difficult when the population prevalence is low.
Table 2: Prevention in various populations

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  Prevention Strategies Top


Coie et al.[1] have suggested that preventive strategies function through one or more of four different ways, that they:

  1. Directly decrease dysfunction
  2. Interact with risk factors to buffer their effects
  3. Disrupt the mediational chain by which risk leads to disorder
  4. Prevent the initial occurrence of risk factors.


There have been extensive reviews of individual intervention programs which have been shown to be effective as preventive measures in childhood and adolescence in developed countries.[13],[14] In general, interventions were found to be more effective when they are delivered to individuals over a prolonged period, i.e. when there were planned attempts at follow-up and staged intervention. Interventions are usually focused on risk or protective factors rather than on specific problem behaviors, and are usually packaged in multi-component packages that can deal with multiple problem areas. Interventions may be directed simultaneously at the individual and at altering the environment (both at home and at school). Specific focus areas have been on aggression and social skills (as universal interventions), for internalizing and externalizing behaviors (as selective or indicated interventions), or for specific risk behaviors such as suicidality.

Another finding worth highlighting is that many educational or social interventions have been used in this area. These are useful for a variety of reasons. First, they are broad-based and provide skills in a number of useful domains. Second, the uses of nonmental health interventions are not associated with stigma or labeling, and are thus politically more acceptable for implementation. However, such interventions cannot be seen in isolation expansion of clinical services are essential for the treatment of those children who do suffer from established mental illness because screening and referral services would be ineffective if there was no capacity to provide effective interventions to those referred. Moreover, these services form part of the secondary and tertiary.

Low- and middle-income countries suffer from constraints of resources, financial support for mental health, and the absence of sufficient capacity, and thus interventions would need to be developed specifically for this setting, or else modified substantially to make them suitable for implementation at scale.[9] Although interventions with established effectiveness are rare. A few example interventions that may be suitable for implementation in this setting are described:

  1. Public educational strategies:[15] A manualized public education campaign has been developed by the World Psychiatric Association in collaboration with the WHO and the International Association for Child and Adolescent Psychiatry (IACAPAP), and tested for effectiveness in nine countries (Armenia, Azerbaijan, Brazil, China, Egypt, Georgia, Israel, Russia, and Uganda). The intervention package had been aimed for use in a variety of targets, including policy-makers, teachers, parents, and children themselves. The manual was delivered by a variety of media (most commonly in print or through local meetings) and had effects on respondents' knowledge of mental illness, confidence in their own awareness, and also in improving self-reported willingness to seek health-care services in case of a mental illness
  2. Parenting and teachers' skills training:[16] Fayyad et al. describe a skills intervention developed to help parents deal with externalizing behaviors in children aged between 6 and 12 years of age, and tested for effectiveness in Lebanon. A five-session training programme was shown to be effective in reducing the negative impact of symptoms on home life, leisure, peer relations, and school
  3. Task-shifting exercises:[17] Strategies that try to make up for the gap in specific child and adolescent mental health expertise have been devised, through the training of teachers, general physicians and pediatricians, to take up roles relating to the identification, initial treatment and referral of children and adolescents with mental illnesses. Huang et al. describe the protocol for a cluster-randomized intervention where early childhood teachers would be trained to deliver behavioral management interventions to children
  4. Adolescent Health Education programs: These are aimed at fostering healthy lifestyles through the use of simple advice. There is a growing body of evidence that such interventions may be useful to delay or prevent substance use disorders (particularly smoking).[6],[18]


These efforts have been supported by the World Health Organization alongside professional bodies such as the World Psychiatric Association and the IACAPAP, which has meant that they are often coordinated and developed for use in a number of developing countries at once. Nevertheless, the evidence base for these activities remains limited. Another deficit is in the area of adapting the literature on the prevalence and relative importance of various risk factors between cultures: the literature on this is mixed, with certain risk factors being similar across countries.[10],[19] Other studies have shown cultural specificities in the structure or risk factors,[20] or in the final outcome of various risks.[21]


  Conclusions Top


Preventive psychiatry has special significance in the period stretching from birth to adolescence, as risks during this period may influence both current and future psychopathology. As no single intervention may be entirely effective, a combination of preventive and promotive interventions that may be delivered by nonexpert personnel may be best suited for use in resource-constrained settings. Before scale-up, it would also be necessary to consider the suitability of such an intervention to the context (and its relationship with the risk factors prevalent in that community) and to appraise the intervention in relation to measures that assess not just the child, but also immediate caregivers and the community as a whole. Ideally, interventions must be delivered and assessed over a long period with developmentally appropriate measures, as the same risk factor may lead to the development of different outcomes, depending on its relationship with other risk factors and developmental parameters.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Coie JD, Watt NF, West SG, Hawkins JD, Asarnow JR, Markman HJ, et al. The science of prevention. A conceptual framework and some directions for a national research program. Am Psychol 1993;48:1013-22.  Back to cited text no. 1
[PUBMED]    
2.
Tudge JR, Mokrova I, Hatfield BE, Karnik RB. Uses and misuses of bronfenbrenner's bioecological theory of human development. J Fam Theory Rev 2009;1:198-210.  Back to cited text no. 2
    
3.
Reisinger KS, Bires JA. Anticipatory guidance in pediatric practice. Pediatrics 1980;66:889-92.  Back to cited text no. 3
    
4.
Joffe A, Radius S, Gall M. Health counseling for adolescents: What they want, what they get, and who gives it. Pediatrics 1988;82(3 Pt 2):481-5.  Back to cited text no. 4
    
5.
Goldstein EN, Dworkin PH, Bernstein B. Anticipatory guidance in pediatric practice: Are we doing more or less. Ambul Child Health 1997;3:4.  Back to cited text no. 5
    
6.
Paperny DM. A new model for adolescent preventive services. Perm J 2004;8:74-9.  Back to cited text no. 6
    
7.
World Health Organization. Caring for Children and Adolescents with Mental Disorders: Setting WHO Directions. Geneva: World Health Organization; 2003. Available from: http://www.myilibrary.com?id=9727. [Last cited on 2017 Apr 08].  Back to cited text no. 7
    
8.
Mental Health: New Understanding, New Hope. The World Health Report. Reprint. Geneva: World Health Organization; 2002. p. 178.  Back to cited text no. 8
    
9.
Remschmidt H, Belfer M. Mental health care for children and adolescents worldwide: A review. World Psychiatry 2005;4:147-53.  Back to cited text no. 9
    
10.
Kessler RC, McLaughlin KA, Green JG, Gruber MJ, Sampson NA, Zaslavsky AM, et al. Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. Br J Psychiatry 2010;197:378-85.  Back to cited text no. 10
    
11.
Gordon RS Jr. An operational classification of disease prevention. Public Health Rep 1983;98:107-9.  Back to cited text no. 11
    
12.
Muñoz RF, Mrazek PJ, Haggerty RJ. Institute of Medicine report on prevention of mental disorders. Summary and commentary. Am Psychol 1996;51:1116-22.  Back to cited text no. 12
    
13.
Greenberg MT, Domitrovich C, Bumbarger B. Preventing Mental Disorders in School-Age Children: A Review of the Effectiveness of Prevention Programs (Report submitted to the Centre for Mental Health Services, Substance Abuse Mental Health Serviced Administration, US Departmetn of Health and Human Services). Prevention Research Center for the Promotion of Human Development, College of Health and Human Development, Pennsylvania State University; June, 2000.  Back to cited text no. 13
    
14.
Durlak JA, Wells AM. Primary prevention mental health programs for children and adolescents: A meta-analytic review. Am J Community Psychol 1997;25:115-52.  Back to cited text no. 14
    
15.
Hoven CW, Doan T, Musa GJ, Jaliashvili T, Duarte CS, Ovuga E, et al. Worldwide child and adolescent mental health begins with awareness: A preliminary assessment in nine countries. Int Rev Psychiatry 2008;20:261-70.  Back to cited text no. 15
    
16.
Fayyad JA, Jahshan CS, Karam EG. Systems development of child mental health services in developing countries. Child Adolesc Psychiatr Clin N Am 2001;10:745-62, ix.  Back to cited text no. 16
    
17.
Huang KY, Nakigudde J, Calzada E, Boivin MJ, Ogedegbe G, Brotman LM. Implementing an early childhood school-based mental health promotion intervention in low-resource Ugandan schools: Study protocol for a cluster randomized controlled trial. Trials 2014;15:471.  Back to cited text no. 17
    
18.
Ozer E, Adams S, Lustig J, Millstein S, Wibbelsman C, Elster A, et al. Do clinical preventive services make a difference in adolescent behavior? J Adolesc Health 2003;32:132.  Back to cited text no. 18
    
19.
Borges G, Nock MK, Haro Abad JM, Hwang I, Sampson NA, Alonso J, et al. Twelve-month prevalence of and risk factors for suicide attempts in the World Health Organization World Mental Health Surveys. J Clin Psychiatry 2010;71:1617-28.  Back to cited text no. 19
    
20.
Goodman A, Fleitlich-Bilyk B, Patel V, Goodman R. Child, family, school and community risk factors for poor mental health in Brazilian schoolchildren. J Am Acad Child Adolesc Psychiatry 2007;46:448-56.  Back to cited text no. 20
    
21.
Mulatu MS. Prevalence and risk factors of psychopathology in Ethiopian children. J Am Acad Child Adolesc Psychiatry 1995;34:100-9.  Back to cited text no. 21
    



 
 
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