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Related Topics
Early Intervention Programs and PoliciesReview - Early Intervention Programs and Policies
The Crisis in Youth Mental Health Vol. 4
by Norman F. Watt, Catherine Ayoub, Robert H. Bradley, Jini E. Puma, and Whitney A. LeBoeuf
Praeger, 2005
Review by Mark Welch, Ph.D.
Aug 8th 2006 (Volume 10, Issue 32)

The Praeger Child Psychology and Mental Health series has previously covered childhood disorders, adolescent disorders and issues for families, schools and communities. Now its attention is turned to early intervention programs and policies. The editors of this volume suggest that one in ten children and adolescents suffer from a mental disorder severe enough to warrant treatment. Yet, they go on to stress, less than half receive treatment and for many the treatment is inadequate. Whether or not the actual prevalence and incidence rates are increasing is a matter of debate. It could be that awareness and detection are increasing and confounding the issue. Nevertheless, the fact remains that some of the most vulnerable groups in our society are exposed to, rather than protected from significant psychological stressors that are expressing themselves in unprecedented rates of mental illness. This makes for the crisis in question.

However, identifying the crisis, is not, in itself, sufficient. The crucial question is whether or not it is possible to act in such a way as to either minimize or ameliorate the expression of mental disorders in these groups. Will intervening early actually do anything of benefit? Can it change the course of an illness? Will the proverbial stitch in time save nine?

The editors concentrate on the USA, but adopt a wide-ranging and multi-disciplinary approach to the issues. The focus on specific US programs need not be a limitation as the principles are readily assessed. There is a strong emphasis on the social determinants of health, poverty being the foremost among them. It is suggested that in recent decades the poverty gap, the proportional difference between the rich and the poor is increasing rather than decreasing: the rich are getting richer and the poor are not. There is an effort to reclaim the seriousness of the bumper sticker aphorism that it takes a village to raise a child. "What constitutes that village?" the authors ask. "Why are some villages so much better endowed than others?"

The book is set out in a number of sections that deal with the roles of society in general, the role of the home and the family, child care and preschooling, and prevention and promotion. In the first section the notion of developing social capital is expounded to include education policy, housing policy and the positive steps towards capacity building. A strong case is made that although the cost of investing in human capacity building may seem high, the cost of not doing so is higher still. The critique of monetarist or free market economic policies is advanced, and it is argued that the short-sightedness is a recipe for social disaster – and one expression of the social unraveling is in youth mental health issues. The writing, it is suggested, is already on the wall. Who now is going to read it?

So far, so predictable. This is not the first book to advance a critique of this nature. However, a number of significant chapters take the argument a little further and begin to look at the impact and structure of programs of intervention, and apply a praiseworthy academic rigor to the evaluation and assessment.

The authors are careful to acknowledge the progress in genetics over recent times, but also maintain that believing in genes does not mean being a genetic determinist. There are multiple levels and layers of influence, and they all tend to work with and within each other rather than separately. However, while the genes cannot be altered (hair-splitting science fiction excepted), the environment can.

So what works? What can be done? What should be done? Four major systems that impact on a child's development are highlighted: the family (which is seen as the most important), the health system (which is seen to be too often ignored), the education system (which has become the focus of US domestic policy) and the child care system (where it is suggested most children spend their pres-school years). Although the last of these is a little shakily defined, these categories, while not exclusive, do provide points of leverage and intervention. They also, as in the case of the Abecedarian Program, provide points of intervention in common.

A good example is made of the Abecedarian Program. It was developed in Carolina for children at risk of school failure. A randomized trial was conducted and the children were allocated at between 6 and 12 weeks of age to minimize the impact of other developmental influences. It operated a multi-focus intervention and included language development and family involvement. The participants were followed up to the age of 21 and although the cost of the program was high, so were the dividends. Grade retention and post-secondary study rates went up, special education needs went down. Lifetime earning capacity estimates increased by more than $37,000. Smoking rates decreased and mortality decreased, but criminal behavior did not. Overall, it was estimated that for every $1 invested in the program, $4 of benefits were generated. It may have been interesting to consider some of the wider aspects of mental health such as drug use other than tobacco, or social relationships, for example divorce.

It would seem that according to the authors, not only do early intervention programs work (when done properly), but the earlier the better. There is also a need for careful and thorough evaluation strategies. However, it is a curiosity of the book that although it begins by proclaiming a crisis in youth mental health, the actual mental health concerns and issues are often buried in general social psychological developmental approach. We learn less about early intervention in mental illnesses than we might expect. We do not learn, for example, whether early intervention of this nature has profound or durable effects on suicide rates or psychotic illnesses (although substance abuse is recognized). There is not as much correlation with psychiatry as might be assumed.

Nevertheless, it is a welcome addition to the literature and it is encouraging to see a rigorous scientific approach being taken towards the more value-laden policy and program debate. Evidence like this will never completely win the philosophical argument, but if we do not clearly and honestly evaluate the consequences of policy decisions, we will always be mired in the claim and counter-claim of politics.

© 2006 Mark Welch

 Link: Publisher's web page for Child Psychology and Mental Health series

Mark Welch, Ph.D. Assistant Professor in the Faculty of Nursing at the University of Alberta, Edmonton, Alberta and Co-Director of the PAHO/WHO Collaborating Centre for Nursing & Mental Health


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