ABSTRACT | PDF

EDITORIAL

"Child & Adolescent Mental Health"

Shyamanta Das
Assistant Professor of Psychiatry
Silchar Medical College and Hospital

The 36th Conference of Eastern Zonal Indian Psychiatric Society (CEZIPS 2010) had “Child & Adolescent Mental Health” as its theme.

Studies specifically of psychiatric disorders in children report that between 3 per cent and 18 per cent of children have a clinically significant psychiatric disorder, a number far exceeding those with access to treatment.[1] A recent study which included data on age of onset found that 50 per cent of psychiatric disorders had their onset by age 14, and 75 per cent by age 24.[2] The brain is still highly plastic during childhood and adolescence.[3]

The World Health Organization has defined health as 'a state of physical, mental and social well-being and not merely the absence of disease or infirmity',[4] and mental health as 'a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community'.[5] Communities have acted to suppport the health of their members throughout history.[6]

It is not uncommon for individuals who have come to meet criteria for a mental health disorder such as schizophrenia or depression to have had a preceding period of subtheshold 'prodromal' symptoms, but healthy individuals also have occasional subtheshold symptoms that revolve without intervention.[3] The science of developmental epidemiology has arisen as a response to the recognition that mental disorders may manifest in different ways over the lifespan, and that certain types of symptoms at one age may indicate that an individual is at high risk for developing a different disorder at a later stage of maturation.[7]

John Snow identified tainted drinking water from a particular well as the root of a cholera epidemic in London, which he did based solely on epidemiological observations. Removal of the pump handle stopped the epidemic and proved that exposure was a causative risk, decades before the bacteria itself was identified. We are currently in a similar situation to Snow in regards to connecting risk factors to mechanisms for many mental health disorders.[3]

The recognition of the importance of context in development has led to an elaboration of the different overlapping systems, or ecologies [8] that a child resides within and which present unique risks and opportunities for intervention.[3]

Recognition of the value of considering prevention research as an iterative process led to the formulation of the preventive research cycle.[9] The randomized clinical trial continues to be a gold standard for determing whether a preventive programme itself is responsible for observed changes and thus to establish causality.[3] Effectiveness is defined as showing a positive result in pilot studies under highly controlled circumstances, and efficacy indicates a programme is also able to produce results in the less-optimal conditions associated with larger-scale trials.[3]

The first widely used public health prevention categories were proposed by the Chronic Disease Commission in 1957, who classified prevention as being primary, secondary, or tertiary.[10] An alternative classification system based upon risk-benefit considerations for preventive interventions was introduced by Gordon in 1983 [11] and disseminated through the seminalInstitute of Medicine report in 1994.[9] In this system, prevention is classified as universal,selected, or indicated, depending on the degree of individual risk.[3] An alternative conceptualization of how to proactively intervene to improve outcomes is health promotion, defined as measures to increase likelihood of wellness as a positive quality rather than limiting efforts to decreasing risks for a negative outcome.[12]

The degree of implementation of preventive measures for mental health disorders in children and adolescents depends largely on how convincingly specific risk factors can be demonstrated which are malleable to politically and economically feasible actions.[3] Increasing attention is being paid to social capital, a concept which broadly refers to aspects of social organization and community norms that facilitate the ability of individuals to work together for mutual benefit.[13,3]

Universal prevention programmes have the significant advantage of not conferring stigma upon participants.[3,14] A seminal study in the prevention of depression was performed by Clarke and colleagues,[15] who showed that cognitive therapy in adolescents with subsyndromal symptoms of depression and a depressed parent could reduce the incidence of new cases of depression compared to a control group.[3] Schizophrenia has become a target of preventive medicine through studies showing that treatment of adolescents with early symptoms of psychosis may delay onset of a full psychotic break.[16]

Common themes in 'best-practice' mental health prevention programmes have included the need for multimodal approaches which simultaneously address both the child and components of the environment, and the increased durability of improved outcomes when interventions are maintained for significant lengths of time.[3] In general, meta-analyses have found that preventive programmes in mental health for selected and indicated populations have small to moderate effect sizes, similar to those seen in other areas of medicine.[3]

Technological advances in neuroimaging, genetics, and computational biology are providing the tools to start describing the biological processes underlying the complex course of development, and have renewed appreciation of the role of development, and have renewed appreciation of the role of the environment in determining how a genetic heritage is expressed.[3] It is to be hoped that as our understanding of these disorders grows, public policies to prevent the development of mental health disorders in children will become as commonplace a responsibility for modern societies as the provision of clean drinking water.[3]
References
1. Costello, E.J., Egger, H., and Angold, A. (2005). 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. Journal of the American Academy of Child and Adolescent Psychiatry, 44(10), 972-86.
2. Kessler, R.C., Berglund, P., Demler, O., et al. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.
3. Lenroot, R. (2009). Prevention of mental disorder in childhood and other public health issues. In New Oxford Textbook of Psychiatry (2nd edn.) (eds. M.G. Gelder, N.C. Andreasen, J.J. Lopez-Ibor Jr, and J.R. Geddes)
4. WHO. (2001). Basic documents. World Health Organization, Geneva.
5. WHO. (2001). The world health report 2001: mental health: new understanding, new hope. World Health Organization, Geneva.
6. Tulchinsky, T.H. and Varavikova, E. (2000). The new public health: an introduction for the 21st century, In (eds K. Rhoshel, and M.D. Lenroot). Child Psychiatry Branch, National Institute of Mental Health, pp. 5-54. Academic Press, San Diego.
7. Costello, F.J and Angold, A. (2009). Epidemiology of psychiatric disorder in childhood and adolescence. In New Oxford Textbook of Psychiatry (2nd edn.) (eds. M.G. Gelder, N.C. Andreasen, J.J. Lopez-Ibor Jr, and J.R. Geddes)
8. Greenberg, M.T., Domitrovich, C., and Bumbarger, B. (2001). The prevention of mental disorders in school-aged children: current state of the field. Prevention & Treatment, 4(1), 1-62.
9. Mrazek, P.B. and Haggerty, R.J. (1994). Institue of Medicine (U.S.). Committee on prevention of mental disorders, United States. Congress. Reducing risks for mental disorders: frontiers for preventive intervention research. National Academy Press, Washington, DC.
10. Commission on Chronic Illness. (1957). Chronic illness in the United States. Harvard University Press, Cambridge, MA.
11. Gordon, R.S., Jr. (1983). An operational classification of disease prevention. Public Health Reports, 98(2), 107-9.
12. WHO. (2004). Prevention of mental disorders: effective interventions and policy options summary report. World Health Organization, Geneva. 
13. WHO. (2004). Promoting mental health: concepts, emerging evidence, practice. World Health Organization, Geneva.
14. Cuijpers, P. (2003). Examining the effects of prevention programs on the incidence of new cases of mental disorders: the lack of statistical power. The American Journal of Psychiatry, 160(8), 1385-91.
15. Clarke, G.N., Hornbrook, M., Lynch, F., et al. (2001). A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed patients. Archives of General Psychiatry, 58(12), 1127-34.
16. McGorry, P.D., Yung, A.R., Phillips, L.J., et al. (2002). Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms. Archives of General Psychiatry, 59(10), 921-8.

 

Creative Commons License
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

Nach oben