Primary Prevention in Child and Adolescent Psychiatry-An Overview

ABSTRACT Although primary prevention has been a concern among child mental health professionals for many years, progress in the field has been slow and is fraught with conceptual and methodological difficulties. The aim of this paper is to provide an overview of the topic, highlight some of the more consistent findings, and make suggestions about future development. While it is now generally agreed that intensive primary prevention programmes targeting high risk pre-school children and starting early in the child's life can be effective, much less is known about programmes targeting older children. There is also growing evidence that the participation of the child alone in these programmes--without changing the social context with which the child is in touch everyday--is insufficient to produce sustained improvements. Further development in the field should be guided by a better understanding of the risks and protective mechanisms, and how these affect the child's outcome. In Hong Kong, where child psychiatric morbidity is comparable to that of the West and there are only limited treatment resources, primary prevention needs to be systematically developed as a matter of urgency. Key words: Child Psychiatry; Effectiveness; Primary Prevention; Protective Mechanisms INTRODUCTION It is now well recognised that the community prevalence of child and adolescent psychiatric disorders ranges between 15% and 20%, the commonest of which are disruptive behaviour disorders and emotional disorders. However, few of these children are known to either mental health or social work professionals--1 in 10 in the Isle of Wight study1 and 1 in 6 in the Ontario Child Health Study.2 The remaining majority are not below 'case' level, and intervention is warranted. Many factors contribute to the discrepancy between those in need and those receiving help. The lack of resources is only one factor and, even if treatment for all those in need could be offered, not all children and their families would be willing to accept mental health services. Moreover, those willing to receive treatment may not be the most severely impaired. (3) Once a disorder is established, there is a great deal of suffering for the child, the family, and others in the wider social context such as peers, teachers, and society in general. While promising treatment strategies, with at least demonstrable short-term benefits, are now accumulating for some disorders, it is also clear that not all children will respond. (4,5) Motivation of the family and the degree of psychopathology within the family are crucial factors for predicting continuation and success with treatment. Children do not grow out of their problems and it is well known that continuities exist between childhood and adult psychopathologies, particularly for antisocial behaviours, conduct disorder, (6) and depression. (7) Rutter pointed out that continuities exist not only at the symptom level but also in the individual's style of dealing with life circumstances, which increase the risk of morbidity.6 Nevertheless, continuities are not inevitable, and can be altered by subsequent positive experiences. In light of these concerns, the possibility of preventing some of the more common disorders has been an issue with mental health professionals for many years. Unfortunately, progress in the field has been slow. Although much has been published on the topic, there are relatively few well-established findings. Reasons for the slow progress are the difficulties associated with the planning and evaluation of preventive research. Firstly, if primary prevention is defined as intervention before the onset of symptoms, the arbitrary nature of the thresholds for diagnosing some of the disorders makes it hard to distinguish between primary and secondary preventive efforts. Secondly, a programme's stated targets and goals may not be backed by sound theories, for although risk factors, and more recently, protective factors can be readily listed, the underlying mechanisms leading to dysfunction or protection are still poorly understood. …

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