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Prevention of mental health problems in children - including young offenders
The evidence base
= Barbara Maughan
= MRC Social, Genetic and Developmental Psychiatry Centre
= Institute of Psychiatry, King’s College London
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Why prevention?
–<= /span>general populatio= n UK 5-16 year-olds 10% = ;
–<= /span>young offenders 33% <= /div>
–<= /span>looked after chil= dren 45% <= /div>
•many go untreated =
•long-term outlook is often poor= = for individuals
–<= /span>many disorders pe= rsist / recur into adulthood
–<= /span>education, employ= ment, relationships and parenting may be affected =
•…and costly to society
–<= /span>e.g. boys with Co= nduct Disorder cost 7 times more
–    than non-disordered by their late 20s
•
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‘Children’s mental health and development have never been the focus of long-term, committed public health= intervention in t= he way that early physical health and development have been. <= /span>
It may be coincidental that there is no evidence of a fall in the prevalence of child psychopathology in recent = decades, a period= that has seen such dramatic improvements in physical health and development.
= We think not.’
Costello & Angold, 2000
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Public health strategy for children’s mental health=
=
All children= 3;
Promote healthy development
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Public health strategy for children’s mental health=
=
All children= 3;
Promote healthy development
At risk groups&= #13;
Prevent disorder
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Public health strategy for children’s mental health=
=
All children= 3;
Promote healthy development
At risk groups&= #13;
Prevent disorder
With problems&#= 13;
Treat
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What sorts of evidence do we need?
•= epidemiology of disorders
•= risk / vulnerability factors
<= span style=3D'font-size:71%;color:yellow;text-shadow:auto'>–individual <= /i>
<= span style=3D'font-size:71%;color:yellow;text-shadow:auto'>–‘environmen= tal’
•= resilience / protective factors
•= interventions
<= span style=3D'font-size:71%;color:yellow;text-shadow:auto'>–efficacy =
<= span style=3D'font-size:71%;color:yellow;text-shadow:auto'>–effectiveness = ;
<= span style=3D'font-size:71%;color:yellow;text-shadow:auto'>–cost-effectivenes= s
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Epidemiology of child mental health problems – = the evidence b= ase
<= span style=3D'font-size:75%;color:yellow;text-shadow:auto'>•Disruptive beh= aviour disorders
•     (Conduct, ODD, = ADHD, aggression etc)
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>chi= ldhood onset (can be very early…)
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= predominantly male
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>als= o: adolescent onset CD / delinquency
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= less marked sex differences
<= span style=3D'font-size:75%;color:yellow;text-shadow:auto'>•Depression = ;
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>ado= lescent onset
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= predominantly female
<= span style=3D'font-size:75%;color:yellow;text-shadow:auto'>•Anxiety disorders
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>chi= ldhood and adolescent onset
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= predominantly female
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child
family
peers
school
neighbourhood
community
culture<= /div>
material circumstances
SES
parenting
parents<= /div>
Risk factors for mental health proble= ms in childhood -  an ecological model
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Preventive interventions –
stages of research
•efficacy trials, under ‘ideal’ conditions
•effectiveness trials, under real-life conditions
•dissemination research
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Preventive interventions
standards of evidence
•Evidence for <= /i>= efficacy under optimal conditions
•programme clearly operationalized
•sho= wn to be superior to other approaches / no treatment
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:71%;text-shadow:auto;color:white;mso-color-index:0'>= random assignment / other rigorous comparison
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:71%;text-shadow:auto;color:white;mso-color-index:0'>= adequate sample size to assess effects
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:71%;text-shadow:auto;color:white;mso-color-index:0'>= consistent results across measures
•mai= ntenance of positive effects at follow-up
•con= sistent effects across at least 2 studies
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>= ideally conducted by different groups
R= 11;
Society for Preve= ntion Research
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= Preventive interventions
standards of evidence
•Programmes acceptable for dissemination if:
•evidence of efficacy under optimal conditions
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•eff= ective in real-world conditions (replicated) <= /span>
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•can= be implemented at population level
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>= training, manuals, infrastructure etc
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•sup= portive cost-benefit information
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•too= ls for monitoring and evaluation
•
•
•
R= 26;
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‘rarely have programs supported in policy and practice met these standards… 
The process we are recommending takes time and runs = counter to the heightened sense of urgency often voiced by advocates who bel= ieve that we need to act now.  = 3;
The history of policy making in parenting and early childhood interventions suggests that acting with insufficient data can be wasteful of resources and hope.  In the long run, building solid programmati= c and scientific foundations will get the desired results m= ore efficiently’. 
Olds et al, 2007 &#= 13;
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<= span lang=3DEN-US style=3D'font-size:64%;color:yellow;mso-special-format:lastCR; display:none'>
•Disruptive beh= aviour disorders
•     (Conduct, ODD, = ADHD, aggression etc)
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>chi= ldhood onset (can be very early…)
<= span style=3D'font-size:83%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= predominantly male
<= span style=3D'font-size:83%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= long-term outcome poor
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>als= o: adolescent onset CD / delinquency
<= span style=3D'font-size:83%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= less marked sex differences
<= span style=3D'font-size:83%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= long-term outcome less problematic
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Disruptive behaviour disorders – risk factors<= i>
•<= /span>Individual = 3;
–genetic
–neuropsychological
–temperament / personality
–cognitive
–interpersonal
•<= /span>E= nvironmental
–family <= /span>
•composition, stability, discord
•poverty, SES
–parents =
•stress, mental health, relationships
–parenting
•sensitivity, behaviour management, supervision, = monitoring
–peers
–neighbourhood, school
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Risk factors for disruptive disorders=
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= often co-occur / overlap
•<= /span>? which are key ‘causal’ elements?
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= vary in salience across development
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= marked individual differences in response
•<= /span>? cumulative ‘burden’ of risk most salient
<= span style=3D'font-size:83%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= individual (including gene-) environment interplay <= /span>
•Need to target=
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= active, ‘strong’ risks (causal)
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= multiple risks
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= where timing of effects known
–=       = (shutting the stable door…)
<= span style=3D'font-size:86%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= are modifiable in a cost-effective way
–
•&= #13;
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= Preventing disruptive behaviours
– the evidence base
•extensive = 3;
•programmes
–universal <= /div>
–targeted (= young mothers, low SES, child behaviour)
–across developmental periods =
•pregnancy à infancy
•pre-school
•early school years
•adolescence
–targeting <= /div>
•parenting
•maternal and child health and well-being= 3;
•child behaviour
•cognitive skills / school readiness
•social skills
•classroom / school
•poverty
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= Preventing disruptive behaviours
– the evidence base
•evaluations <= /b>
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= many rigorously-conducted efficacy studies
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= some evaluations outside research contexts
•outcomes=
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= many short-term, some long-term follow-ups
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= some statistically and clinically worthwhile gains
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= some encouraging cost-benefit analyses
•…continuing challenges
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<= span style=3D'font-size:64%;text-shadow:auto;color:yellow'>Preventing disruptive behaviours –
some examples
•Fast Track = ;
•low SES, disruptive children (ages 6/7 years)
•components = ;
•group-based parent training (grades 1-6)= 3;
–parenting skills, parent-child interactions
•home visits to support <= /div>
•group-based social skills training for children
•peer-pairing with no-risk peer <= /span>
–positive modelling, changing peer perceptions
•academic tutoring
•teacher support for effective classroom management
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Fast Track: outcomes at grade 9
highest risk age 6/7
(top 3%)
moderate risk age 6/7
(< top 3%)
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<= span style=3D'font-size:64%;text-shadow:auto;color:yellow'>Preventing disruptive behaviours –
some examples
•Montreal Longitudinal Experimental Study
•= low SES, disruptive boys (age 6 years)
•Components (2 years)
•= group-based social skills training for children
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= small groups, 3 prosocial: 1 disruptive child
•= parent-training
•= information and support to teachers
• <= /b>
•Outcomes age 2= 4
•= Control    Intervention Normative
•= = High school graduation       32         = ;   46=         53
•= Crime record       33        = ;        22=         16
Boisjoli et al, 2007
------=_NextPart_01C835A5.7AC1DB20 Content-Location: file:///C:/D8F3D50E/MaughanPreventionofmentalhealthproblemsinchildren_files/slide0048.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Prevention of mental health problems in children - including young offenders The evidence base
Preventing disruptive behaviours –
some examples
•High / Scope P= erry Preschool
•<= /span>= low income children at high risk of school failure
•Components = ;
•<= /span>= high-quality, active learning pre-school programme = ages 3-4
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= promoting cognitive and social development
<= span style=3D'font-size:63%;color:white;mso-color-index:0;text-shadow:auto'>•= weekly home visits by teachers
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= discuss and practice parent-child activities
------=_NextPart_01C835A5.7AC1DB20 Content-Location: file:///C:/D8F3D50E/MaughanPreventionofmentalhealthproblemsinchildren_files/slide0030.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Prevention of mental health problems in children - including young offenders The evidence base
High/Scope Perry Preschool
outcomes age 40
Schweinhart, 2005
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jMrzWwILMAER0L1mckcSQLx9DMqkycJlMAFheLwlgLvh+8XMjL1ibAblO8pWUsBuPLvJs8bsrKV9 YhQxUbzvLKUFYH/cXM86EAIAOw== ------=_NextPart_01C835A5.7AC1DB20 Content-Location: file:///C:/D8F3D50E/MaughanPreventionofmentalhealthproblemsinchildren_files/slide0057.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Prevention of mental health problems in children - including young offenders The evidence base
Cost effectiveness
•int= ensive programmes are expensive…
•but long-term costs of disruptive disorders are also exp= ensive
•and (arguably) need to be assessed in long-term
•Perry Preschool
• estimated savings of
–$7<= span style=3D'mso-spacerun:yes'>   per $ invested by age 27= 3;
–$16= per $ invested by age 40
•= mainly crime-related savings
•+ education savings
•+ increased income tax
•+ decreased welfare dependence
•<= /span>
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Characteristics of successful interventions
•com= prehensive – include several components
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>? combining universal and targeted interventions
•att= ention to most effective mode of intervention / teaching
•suf= ficient dosage / intensity
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>? gauged to level of risk
•the= ory-driven
•opp= ortunities for positive relationships
•app= ropriately timed and developmentally sensitive
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>= early enough to affect targeted outcomes <= /span>
•acc= eptable to participants / socio-culturally relevant
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>= home-visiting / parenting: engagement and retention crucial
•wel= l-trained staff
Nation et al, 2003
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Preventing violence and related behaviours
•What doesnR= 17;t work….
•agg= regating high-risk young people together (contagion)
•poo= rly articulated implementation protocols
•sta= ff not well supervised, not accountable
•pro= grammes limited to
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>= scare tactics
<= span style=3D'font-size:64%;color:white;mso-color-index:0;text-shadow:auto'>–<= span style=3D'font-size:64%;text-shadow:auto;color:white;mso-color-index:0'>= ‘toughness’ strategies
<= span style=3D'font-size:63%;color:white;mso-color-index:0;text-shadow:auto'>•pro= grammes that largely consist of adults lecturing young peo= ple
National Institutes of Health State-of-the-Science Conference Statement (Lochman, 2006)
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R= 26;Depression = ;
–adolescent onset
•predominantly female
•remitting, recurring course
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Depression – risk factors
<= span style=3D'font-size:75%;color:yellow;text-shadow:auto'>•Individual = 3;
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= genetic  (and gene x environment interactions)
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= neurobiological
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= temperament / personality
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= negative cognitions
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= coping styles
<= span style=3D'font-size:75%;color:yellow;text-shadow:auto'>•Environmental&= #13;
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>stress / trauma / daily ‘hassles’ =
–= problematic peer and family relationships
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Preventing depression – an exam= ple
•Penn Prevention Program=
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= cognitive-behavioural programme
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= designed to enhance
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= optimistic explanatory style
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= interpersonal problem-solving
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= assertiveness
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= social skills
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= typically
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= 12 weekly small group / classroom sessions
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= delivered by psychologists / trained teachers
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= evaluations of targeted and universal programmes
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Preventing depression<= span style=3D'font-size:64%;text-shadow:auto;color:yellow'>
•Targeted programmes =
•=       (parental divorce, bereavement, elevated depression symptoms)
•<= /span>= reasonably consistent evidence of short-term = benefits, and up to 1 year post
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= reductions in symptom scores and diagnoses
<= span style=3D'font-size:75%;color:white;mso-color-index:0;text-shadow:auto'>•<= /span>= cost-benefit analyses
–<= /span>= comparable with treatment for adult depression
• <= /b>
•&= #13;
Spence & Shortt, 2007
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Preventing depression =
•Universal programmes
•mixed evidence on short-term benefits= 3;
•small (but significant) effects 6-11 mon= ths post
•no longer-term benefits <= /span>
•But
•methodological problems <= /span>
–small, possibly unrepresentative  samples
–? reliability of measures
•Suggested modifications
•longer and more intensive
•booster sessions <= /div>
•reduce risks / enhance protection in child’s environment
–? family component
–? broader supportive changes in school environment
•<= /span>
•
Spence & Shortt, 2007
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R= 26;Anxiety disorders
–childhood and adolescent onset
•predominantly female
R= 26;
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Anxiety disorders – risk factor= s
<= span style=3D'font-size:75%;color:yellow;text-shadow:auto'>•Individual = 3;
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= genetic
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= anxious attachment
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>= behavioural inhibition
<= span style=3D'font-size:75%;color:yellow;text-shadow:auto'>•Environmental&= #13;
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>parental anxiety
<= span style=3D'font-size:71%;color:white;mso-color-index:0;text-shadow:auto'>–<= /span>negative / stressful events
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Preventing anxiety
•cognitive-behaviour training
•derived from effective treatment programme
•10 weekly classroom sessions
•2-4 parent sessions
–coping with own anxiety <= /span>
–contingency management for children<= /span>
•<= /span>
•encouraging results from targeted and universal programmes
•follow-ups to 36 months <= /span>
•most effective for
–younger children (ages 10-12 years) - ? older too late
–girls; higher risk
•<= /span>requ= ires replication by independent research teams
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Universal approaches <= span style=3D'font-size:64%;color:yellow'>
•promoting competencies in all young people
–Social and Emotional Learning
•addressing broader risk factors / enhanc= ing social systems
–income support
–maternal mental health
–school, community characteristics= =
•Evaluation evidence
•= e.g. re school-based initiatives
•numerous projects reported
–school-wide change
–changes in classroom organization / routine
–changes in psychosocial environment of classroom / school
•fewer with quantitative evaluations =
•initial reports encouraging
–monitoring implementation crucial
•<= /span>
•<= /span>
•
Durlak et al, 2007