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 REVIEW ARTICLE

Primary psychiatric prevention in children and adolescents

Mark Opler, PhD

New York University School of Medicine, New York, NY, USA

Dimple Sodhi, MD

SUNY Downstate Medical Center, Department of Psychiatry, Brooklyn, NY, USA

Deval Zaveri, MD

SUNY Downstate Medical Center, Department of Psychiatry, Brooklyn, NY, USA

Subramoniam Madhusoodanan, MD

SUNY Downstate Medical Center, Department of Psychiatry, Brooklyn, NY, USA
St. John’s Episcopal Hospital, Department of Psychiatry, Far Rockaway, NY, USA

BACKGROUND: Approximately 21% of US children age 9 to 17 have a diagnosable mental illness with some degree of impairment. As early-onset mental illness may persist throughout the life span, effective primary mental health prevention programs are of paramount importance.

METHODS: We conducted a literature review of various preventive programs targeting childhood-onset psychopathology. We attempted to select those programs that present the strongest data on efficacy and those that are most commonly cited.

RESULTS: Modifiable and nonmodifiable risk factors and different primary prevention strategies with positive outcomes have been identified for anxiety disorders, eating disorders, substance abuse, disruptive behavior disorders, and suicide in children. The reported results for attention-deficit/hyperactivity disorder (ADHD) and early-onset schizophrenia are neither uniform nor encouraging.

CONCLUSIONS: Based on our review, there is ample evidence to conclude that primary preventive intervention has the potential to be effective for some mental health disorders, promoting positive development, particularly in children of all ages in high-risk environments. Additional research is needed to further investigate the validity and reliability of various preventive strategies.

KEYWORDS: primary prevention, psychiatry, children, adolescents

ANNALS OF CLINICAL PSYCHIATRY 2010;22(4):220-234

  INTRODUCTION

According to the Methodology for Epidemiology of Mental Disorders in Children and Adolescents (MECA), almost 21% of US children age 9 to 17 have a diagnosable mental illness with some degree of impairment.1 A 1994 Institute of Medicine report describes a range of interventions for mental disorders that included treatment and maintenance, reserving the term “prevention” for efforts that occur before onset of a diagnosable disorder.2-4

Primary prevention can be divided into 3 subcategories5:

  1. Universal prevention: Targeting the general public or a population group that has not been identified on basis of individual risk.

  2. Selective prevention: Targeting individuals or populations subgroups who have biologic, psychological, or social factors placing them at a higher than average risk for developing mental disorders.

  3. Indicated prevention: Targeting high-risk individuals with detectable symptoms or biologic markers predictive of mental disorder who do not yet meet criteria for diagnosis.

As per the US Surgeon General’s report on mental health, each year 20% of children and adolescents experience symptoms of a mental disorder.3 There is compelling data suggesting that only one-third or less ever receive appropriate treatment.6-8 An estimated 30% of children age 14 to 17 engage in multiple high-risk behaviors, 35% are considered to be at medium risk, and 35% have little or no involvement, but require strong and consistent social support to prevent behaviors that could be subsyndromal manifestations of conduct disorder.3,9,10

Prevention in this population can be extremely challenging because many young children do not have access to environmental supports that protect against high-risk behavior and encourage positive or preventive behaviors.3,8 The range of detrimental conditions that children and adolescents experience and the potential for mental illness to continue over the life span further signify the importance of effective primary mental health prevention programs for children.8 Successful primary prevention plays a significant role in preventing suffering and maladjustment in many youth who might not otherwise receive sufficient formal mental health care,7 preventing impairment into adulthood.8

A meta-analysis of 177 primary prevention programs by Durlak et al7 indicated that most categories of primary prevention programs for children and adolescents produced significant effects and provided empiric support for further research and practice in this field.

In this review, we will summarize primary preventive programs for selected mental disorders in children and adolescents. Because an exhaustive exploration of all published efforts is beyond the scope of this review, we have selected those programs that present the strongest data on efficacy and those that are most commonly cited. In lieu of a new meta-analysis, we have included several programs that were published since the report by Durlak et al.7

Mood and anxiety disorders

Mood and anxiety disorders are common in childhood and have been the focus of preventive efforts. According to DSM–IV, mood disorders include depressive disorders, bipolar disorders, and anxiety disorders common in children include social phobia, specific phobia, generalized anxiety disorder, and separation anxiety disorder. Mood disorders have high comorbidity with anxiety disorders, substance use, and disruptive disorders.11

Environmental factors.

Risk Factors. Children of parents with mood or anxiety disorders are themselves at risk of developing similar disorders.12,13 Subclinical symptoms of depression or anxiety are associated with increased future risk of a depressive or anxiety disorder, respectively.14,15 Negative life events, such as the death of a parent, parental separation or divorce, and psychological trauma are also associated with depression and anxiety in children.16 Modifiable and nonmodifiable risk factors and possible interventions for mood and anxiety disorders in children and adolescents are described in TABLE 1.

Protective Factors. Two important protective factors which have been identified by Compas include individual stress coping abilities and social support systems.17 Preventive interventions accordingly may be provided at the level of schools, homes, or clinics, via education, social support, and strengthening individual stress coping abilities. Using different resources and settings, multiple and diverse combinations are possible. Preventive programs in this context can be classified as universal, selective, or indicated.

Universal prevention programs. Universal prevention includes programs integrated in school curricula. They focus on the enhancement of general social/emotional and cognitive skills that can alleviate different behavioral disturbances, including mood and anxiety symptoms. Shrue et al18 described the Interpersonal Cognitive Problem Solving program (ICPS). In this classroom-based program, schoolteachers promote development of language and abstraction skills through education, dialogue, and role-playing. These measures help children develop problem-solving skills, preventing the development of interpersonal dysfunction. The report by Shrue et al demonstrated that ICPS could significantly improve cognitive problem-solving abilities and reduce inhibition and impulsivity. However, there was no decrease in the incidence of psychiatric symptoms at 1-year post-intervention follow-up.18 Another similar program for elementary school children was Promoting Alternative Thinking Strategies (PATHS),19 which also targeted development of cognitive skills and improving emotional and social competence. In contrast to ICPS, PATHS also included instructional interventions, such as teaching about the home and school environment.19 The children in the intervention group showed improvement in problem solving, teacher-rated adaptive behaviors, and self-reported conduct problems. One and 2-year follow-up data showed significant decrease in internalizing (depression and anxiety) and externalizing (attention-deficit/hyperacitivity disorder [ADHD], disruptive) behaviors.

Selective prevention programs target a specific subset of the population. We will begin with a review of programs that address the school environment, followed by a discussion of home-based interventions at various ages.

School-Based Interventions. We have included 3 programs here. The Primary Mental Health Project (PMHP) identified primary school children with learning, emotional, or social difficulties.20 With the direct assistance of well-trained, nonprofessional staff referred to as “Child Associates,” children improved their academic performance and social behavior. One-year post-intervention assessments demonstrated significant positive effects on internalizing symptoms of depression and anxiety and improved academic performance.

Another target of selective prevention efforts is school transition. The Improving Social Awareness-Social Problem Solving program (ISA-SPS) attempts to smooth the transition from elementary to middle school.21 Before a school transition, children receive 2 years of training that strengthens their ability to face related stress. A similar program focusing on smooth transition from elementary to middle and from middle to high school is the School Transitional Environment Project (STEP).22 STEP focuses on the psychological stress related to transitional events in life, easing the adjustment to a new school environment by providing support and structure from teachers and peers. This restructuring produced significantly lower levels of stress, thereby reducing anxiety and depression.

Stress Inoculation Training is a program that helps high school students learn to deal with any stressful life event.23 This program consists of 13 cognitive-behavioral training sessions that focus on correcting maladaptive cognitive skills and enhancing problem-solving skills. After this training, students reported significant reductions in internalizing symptoms of depression and anxiety.

Family-Based Interventions: Pregnancy, Infancy, and Preschool. A number of programs have been developed targeting high-risk families during pregnancy, infancy, and preschool years. The majority of successful preventive programs focus on enhancing early mother-child bonding.24

One program we have identified here focuses on social, educational, and medical support for high-risk pregnant women. The Yale Children Research Project worked with low-income pregnant teens from the prenatal period until 30 months postpartum.25 The mothers were educated about self-care during pregnancy and child-rearing practices. In addition to educational services, they also received social support and medical and nutritional services. After 5 years of follow-up, there was decrease in behavioral problems and mood symptoms in children. The mothers showed greater self-reliance and improved child-rearing abilities.

Treatment of depression during or immediately after pregnancy also has significant protective effects on children. Pooballan et al26 described the damaging effects of postpartum depression on the emotional and cognitive development of children. The authors reviewed 8 trials of treatment for postpartum depression and concluded that providing support with intensive and prolonged cognitive therapies for depressed mothers in the postnatal period significantly improved the mother-infant relationship. Healthy mother-child bonding also may enhance cognitive development in children.

Family-Based Interventions: School-Age Children. Some newer programs have adopted multi-component, multi-systems approaches to reduce risk in a child’s social environment.27,28 One such family-based program led by William Beardslee targets the children of depressed parents. At Judge Baker Children’s Center in Boston, MA, parents with a history of mood disorders and their children participated in a 2-part lecture series, clinician-facilitated talks and family therapy, followed by refresher meetings or telephone contacts at 6- to 9-month intervals.27 The children and parents received psychoeducation about mood disorders and risk/resilience factors. This program helped parents talk about their illness and their achievements and helped children understand their parent’s illness, thereby reducing blame and guilt. The program also strengthened stress coping skills and resilience in children. With these measures, post-intervention internalizing behavior scores declined.

A similar study in Sweden addressed the longing and fear that depressed parents have about communicating with their children.28 This study identified factors that facilitated and inhibited participation in Beardslee’s family program.27 Initially, it was difficult for parents to talk with their children about their illness and the need for professional help. Family sessions reduced this fear, eased communication between parents and children, and helped children understand the mental illness. Increased familial bonding provided a strong social support for the children. Most important, it allowed the children to assess themselves and seek professional assistance when needed.

The Children of Divorce Intervention Project is a preventive program that targets elementary and middle school children.29 The program provides support, education, and information about divorce and attempts to dispel unrealistic beliefs. Children learn to express their feelings and build their self-esteem, thereby improving family and social skills. This intervention helped children deal with the emotional and behavioral aspects of parental divorce.

The Children of Divorce Parenting Program, a similar program aimed at parents, uses a multi-domain approach to strengthen the mother-child relationship and minimize behavioral and emotional problems in children, with benefits seen in the treatment group compared with controls.30

The Family Bereavement Program was designed to support children who experience death or loss in the family by offering educational, social, and psychological support to parents or caregivers.31 This intervention helps families overcome grief and provide warmth, support, and care to bereaved children. The authors reported that the intervention was successful in significantly reducing depressive symptoms and conduct problems in children.

Interventions For Adolescents. Many programs for adolescents are school- or community-based, promoting survival, interpersonal development, and problem-solving skills. They also focus on drug and alcohol use and disruptive behaviors.32

Depression is more prevalent among adolescents born to depressed parents than among adolescents whose parents are not depressed.34 In a randomized controlled trial, children age 13 to 18 whose parents had a history of depression attended 15 sessions of group cognitive therapy to modify their attitudes and beliefs about parental depression.33 At 12 months follow-up, the risk of depression in the control group was 3 times the risk in the intervention group.


TABLE 1

Modifiable and nonmodifiable risk factors with possible interventions for mood and anxiety disorders in children and adolescents

Modifiable factors Possible interventions Nonmodifiable factors
Poor stress coping abilities Promoting stress and anxiety coping skills
Cognitive, emotional, and social skills enhancement
Parent with a mood/anxiety disorder
Poor social support system Fostering the mother-child relationship, providing support, education and treatment (if essential) to the mother
Family therapy sessions
Enhancing school environment (make it one that is more supportive, promotes positive behavior, encourages teacher training)
Negative life events such as death of parents/parental divorce

Indicated prevention programs.

Prevention of Mood Disorders. Indicated programs focus on children with low-grade mood symptomatology. The Coping with Stress Program provided 15 sessions of group cognitive-behavioral therapy to children with minimal to mild depressive symptoms who did not meet DSM-III-R criteria for a depressive disorder.34 Results demonstrated significant decreases in the incidence of major depressive disorder or dysthymia in the intervention group compared with the control group.

Similarly, the Penn Prevention Program taught children with subclinical mood symptoms a series of cognitive-behavioral techniques (including modification of feelings and thoughts), coping skills, assertiveness training, and strategies for dealing with familial and social stress.35 Results showed decreases in parents’ reports of internalizing behaviors immediately after the intervention and at 6-month follow-up.

Prevention of Anxiety Disorders. The Queensland Early Intervention and Prevention of Anxiety Project screened children age 7 to 14 for low-level anxiety disorders.36 Psychosocial interventions were provided to some children and parents, while others were assigned to a monitoring group. Post-intervention assessments showed reduction in anxiety symptoms; follow-up at 6 months and 2 years suggested a decrease in the incidence of anxiety disorders in the intervention group.

Pediatric substance abuse

Despite declining prevalence, substance use (tobacco, alcohol, and illicit drugs) in adolescents continues to be a major public health concern.37,38 Adolescents experiment with substances at higher rates than adults.39 As described by Johnston et al,38 lifetime substance use almost doubles between 8th and 12th grade, indicating that a large proportion of adolescents initiate substance use during high school. Ample data suggest that the earlier alcohol or illicit drug use begins, the greater the risk of developing severe medical conditions (such as human immunodeficiency virus infection), adult substance abuse disorders,37,40-45 academic underachievement,46 delinquency,40,47,48 teenage pregnancy,49-51 and comorbid psychopathology.52-56

The potential risks of early smoking and drinking cannot be overstated. A child who uses alcohol or tobacco is 65 times more likely to use marijuana than a child who does not. Additionally, a child who smokes marijuana is 104 times more likely to use cocaine than peers who do not.57 It is believed that addiction develops from a complex interplay between individual factors (hyperactivity, poor self-image, genetic inheritance, and poor school performance), the environment (dysfunctional family, early exposure to drugs and alcohol, peer pressure, parental rejection, abuse), and the addictive substance itself.41

Universal prevention programs. Universal prevention efforts have long been in place; however, the approach has evolved in recent decades. Before the 1970s, prevention programs were based on an information-deficit model, assuming that children lacked knowledge about the harmful effects of drug use. In the 1970s and 1980s the prevailing theory shifted, assuming instead that youth experimented with drugs and alcohol because they had not developed an internal value system to resist external pressures. This shift led to a focus on social and interpersonal role models. In 1990s, substance abuse prevention programs took a comprehensive systems approach, becoming more interactive, research-based, age appropriate, and culturally relevant.41 There are too many promising prevention programs to review in depth. The modifiable and non-modifiable risk factors and possible interventions are described in TABLE 2.

Selective prevention programs. Effective programs generally have focused on junior high and high school children,41 but there are several notable exceptions. The Child Development Project targeted urban, suburban, and rural elementary schools.58 The model involved classrooms, schools, and families to foster a caring community. Positive outcomes included improved peer relations, reduced drug use, and reduced delinquency.59 The Seattle Social Development Project is an effective program for children in grades 1 to 4.60 Involving families and schools, this program enhanced protective factors against delinquency and substance abuse41 through child social skills training, parenting classes, and teacher training.59 The results were favorable in terms of decreased incidence of drug use, decreased disruptive behavior, and improved school performance.61 The 11-year follow-up continued to show higher levels of achievement in the intervention group, as well as decreased delinquency and pregnancy.59

The Baltimore Prevention Project focused on first graders in public schools. It emphasized curriculum enhancement and teacher training in behavior management, child social skills, and problem solving.62 Positive outcomes included improved school performance and reduced rates of conduct disorder and smoking at 4- to 6-years follow-up.59

The Nurse Home Visitation Project targeted first-time pregnant women of low socioeconomic status, women age <19, and unmarried women. The program involved multiple visits to promote healthy behaviors during pregnancy and early childhood, child-care competency, mothers’ personal development, and enhanced linkage to social and supportive services. Outcomes included improved maternal functioning and reductions in child maltreatment. A 15-year follow-up showed decreases in drug use and antisocial behavior.59,22

Indicated prevention programs. Strengthening the Families Program is an intervention for children age 6 to 10 of drug-dependent parents. This program includes training for families, children, and parents and has resulted in reduced behavior problems, substance abuse in children, and family conflict.41,63

Lopez et al37 conducted a literature review on the neurodevelopmental implications of preventive programs, focusing on adolescents’ substance use. They concluded that adolescents are cognitively immature with respect to the neurologic processes required for decision-making, including making decisions about substance use. Thus, family-based, child-centered primary prevention programs are more likely to produce positive outcomes in adolescents than programs that are only child centered.


TABLE 2

Modifiable and nonmodifiable risk factors and possible interventions for substance abuse in children and adolescents

Modifiable factors Possible interventions Nonmodifiable factors
Hyperactivity
Poor impulse control
Skills and problem-solving training Age (adolescence)
Family history
Dysfunctional family
Parental abuse
Early exposure to drugs
Parental training
Support and timely medical or psychiatric treatment for pregnant mothers
Fostering mother-child relationship
 
Poor school performance Enhancing school environment
Teacher training
 
ADHD and related disorders in children

Disruptive behavior disorders are among the most common and stable psychiatric disorders in children,64 with a worldwide prevalence of 5.29% in 2007.65 In this section we discuss ADHD. Other disruptive behaviors—conduct and oppositional defiant disorders—have been discussed in the subsequent sections. Children with ADHD have elevated levels of inattention, hyperactivity, and impulsivity. These disorders share environmental and genetic components, highlighting the role of neurologic factors in regulation of attention and activity.66

Universal prevention measures. Given the role of environmental and genetic factors in the development of ADHD, prenatal and postpartum environments have been targets for prevention.67 Preventive measures include avoiding prenatal exposure to nicotine,68 alcohol,69 recreational drugs,70 and toxins, such as polychlorinated biphenyls and hexachlorobenzene. Noradrenaline dysregulation caused by congenital or postnatal conditions (eg, cardiovascular and metabolic defects)71 also has been targeted. Early identification of risk factors and appropriate interventions can help prevent or delay onset of ADHD. Strategies include promotion of maternal health during pregnancy, stress reduction, and early detection and treatment of any medical or psychiatric conditions. These approaches have the potential to significantly reduce the risk of ADHD in children.72

Indicated prevention measures.

Parenting And Family Interventions. Inadequate parenting skills are an important target for ADHD prevention. Studies have described the difficulties parents face with their children’s disruptive behaviors. In fact, certain parental attitudes and behaviors can precipitate or reinforce a child’s inappropriate behavior.73,74 The Families and Schools Together (FAST) Program is designed for families whose children exhibit behavioral or academic problems but are not diagnosed with a behavioral disorder.75,76 The program consists of a series of group activities for parents and children in addition to group family sessions to enhance overall family functioning and academic functioning of children. There was reported improvement in conduct problems, anxiety, and attention span.

School-Based Programs. Many preventive mental health interventions directed at children are nonspecific, addressing a range of syndromes rather than a single disorder, such as ADHD. As previously discussed, they are mainly school-based interventions, but often involve families for greater effect. One example is group and supportive therapy sessions for disruptive and hyperactive boys. Boys age <14 were assessed by their teachers using a Social Behavior Questionnaire comprised of 38 items that addressed disruptive, anxious, inattentive, and pro-social behaviors. High-risk boys were identified as those with “disruptiveness scale traits” (eg, aggression, hyperactivity, and oppositional traits) who did not meet diagnostic criteria for a disruptive disorder. These boys received support and social skills training. The trial also involved participation of parents and teachers. The results suggested that early preventive intervention for high-risk children is likely to benefit the children and, in a broader sense, the community.77

Disruptive behavior disorders

Disruptive behavior disorders can have significant adverse effects in later life.64,78 In this section, we will-focus on conduct disorder and oppositional defiant disorder. The British National Child Developmental Study has shown an association between childhood behavioral problems and increased long-term mortality risk.79 Conduct disorder and childhood externalizing problems, including aggressiveness and impulsivity, are strong predictors of antisocial behavior in later life.80-82 These children are likely to have limited academic achievement secondary to cognitive distortion and deficits. They also are likely to endure peer rejection, engage in substance use, experience depression and interpersonal difficulties, and possess inadequate social skills.83-90 Childhood behavioral problems can be transmitted from 1 generation to another91; siblings of children with disruptive behavior are at high risk of acquiring this behavior themselves. Primary prevention programs aimed at high-risk groups have the potential to minimize the incidence and consequences of disruptive behavior disorders.

Several types of primary prevention programs have been described in the literature; notable aspects of some of them are briefly described below.78-82 The modifiable and nonmodifiable risk factors and possible interventions for disruptive behavior disorders in children are described in TABLE 3.

Selective prevention programs. The Montréal Home Visitation Study92 focused on care taking, mother-child interaction, child development, maternal social support, and social interactions. Children from families who participated in this program had fewer injuries compared with ones who did not. These children also had better quality home environment provided to them.82 Another program, described by Olds et al93 entails home visits to single, teenage, or low-income women who are pregnant for the first time, starting before 30 weeks’ gestation. Through social, educational, and medical support, Olds and colleagues reduced children’s externalizing behaviors, such as substance use and disruptive behaviors.

Few programs focusing on adolescents have been successful yet because of high attrition rates; however, this is an area of ongoing research. Some successful programs target very young children with early onset disruptive behavior disorders. For example, the High Scope/Perry Preschool program focused on preventing school failure in low socioeconomic status African American children age 3 to 4. This program had positive outcomes in terms of school performance, graduation, and employment with significant decrease in delinquency.82,94


TABLE 3

Modifiable and nonmodifiable factors with possible interventions for disruptive behavior in children and adolescents

Modifiable factors Possible interventions Nonmodifiable factors
Aggressiveness and impulsivity
Interpersonal difficulties
Poor social skills
Cognitive-behavioral therapy for anger management
Positive role modeling
Enhancing social skills
Genetic inheritance
Male sex
Mother-child interaction
Mother’s social support
Inadequate parental support
Providing support to pregnant women
Timely intervention for medical or psychiatric problems
Fostering mother-child relationship
Parent education and training
 
Poor school performance
Support from peers and teachers
Promoting positive behaviors
Coping skills training
Teaching skills for impulse and pressure control
 

Indicated prevention programs.

Family- And Parent-Focused Programs. Patterson et al74 and Forehand et al95 demonstrated the short-term effectiveness of the social learning programs The Incredible Years: Parents, Teachers and Children Series and Helping the Noncompliant Child. These programs were designed for families with young children who exhibited subsyndromal disruptive behavior. Working with a similar population, Webster-Stratton96-98 showed long-term improvement in children’s behavior (more pro-social behavior and less negative behavior) with family- and parent-focused programs, such as the PARTNERS program. Despite reports from several effective, family-focused programs, there is insufficient evidence that educating parents can prevent disruptive behaviors in children and adolescents.

Child-Focused Programs. Lochman et al99 developed a cognitive-behavioral school-based program focused on anger management in aggressive elementary and middle school boys. There was a decrease in aggressiveness and disruptive behavior immediately after the intervention. At 3-years follow-up, children’s on-task behavior was maintained, especially in those who received booster sessions in the intervening school year.100

Studies also have shown that children with subsyndromal conduct disorder benefit from integration in a group of normative peers as pro-social models.101 Improvements observed in the child’s social skills and interpersonal interactions could prevent development of a conduct disorder. One example of a program that improves the interpretation and perception of other people’s actions is the BrainPower Program102-104 that targets children who display aggressive behavior. This intervention reduced hostile behavior, and follow-up showed that participants maintained their positive behavior.

Multi-Component Programs. Because of the limited effectiveness of programs that focus solely on either the child or the parent, multi-component programs such as Fast Track have been developed.105-108 Fast Track is a school-wide program that integrates all 3 approaches to prevention (universal, selective, and indicated) and targets the family, peer group, school, and community. Results from the first 3 years demonstrated significant decreases in special education referrals and aggressive behavior at home or in school, with improvement in social skills and academic development. Another multi-component intervention, the Earlscourt Social Skills Group Program,109,110 targets children, parents, and the classroom environment. The intervention group showed fewer externalizing behaviors than control.

Prevention programs for infants and toddlers at high risk of developing maladaptive behaviors focus on educating parents. In contrast, programs for preschoolers, elementary school children, and adolescents often involve family and parents only to a limited extent. Success may require a program that addresses multiple risk factors simultaneously, involves family members and other stakeholders, and considers developmental issues. Use of standardized interventions may enable their replication in other settings.82

Childhood eating disorders

Restrictive and purging disorders. Eating disorders such as anorexia nervosa and bulimia nervosa are among the most prevalent psychiatric disorders in female adolescents and pre-adolescents. They cause subjective distress and impaired functioning, leading to an increased risk of suicide, obesity, and multiple medical and psychiatric comorbidities.111 Long-term, untreated eating disorders can become intractable and may prove fatal,112 amplifying the need for effective prevention programs. Because the peak incidence of eating disorders in girls occurs in mid-adolescence,113 there is a need for concerted school-based approaches.

The first universal eating disorders prevention programs were based on the hope that awareness about the adverse effects of eating disorders would discourage individuals from maladaptive behavior. The primary strategies used in these interventions were didactic teaching and psychoeducation. Second-generation universal prevention programs remained didactic in nature, with additional components to build resistance to the sociocultural pressures to be “thin.” These programs assumed that pressure to be thin plays a key role in the etiology of eating disorders, causing adolescents to use radical methods to limit weight gain.

The latest generation of prevention programs target selected high-risk populations with interactive exercises, focusing specifically on risk factors shown to predict the onset of eating disorders, such as body dissatisfaction.111

A meta-analysis of prevention programs reported that 51% of eating disorder programs decreased risk factors such as body dissatisfaction and 29% decreased current or future eating disorders.114 In 2004, Stice et al111 studied 38 different prevention programs in 53 controlled trials and found that the most effective programs were selective (vs universal), interactive (vs didactic), multi-session (vs single session), female oriented (vs both sexes), offered to adolescents age ≥15 (vs younger children), and were delivered by professional interventionists (vs providers who were not professionally trained) with shorter follow-up periods. Successful programs focused on body acceptance rather than psychoeducation alone.

Early studies showed that internalization of body image ideals in the media is a major risk factor for eating disorders and could be an effective target for prevention programs.115 However, in a study of mid-to-late adolescent girls enrolled in programs that addressed either media literacy or perfectionism—another suspected risk factor for eating disorders—the media literacy approach was not as effective as in younger or older participants.116,117 These results suggest the importance of designing prevention programs that are developmentally appropriate for their target audience.

Obesity is a major public health problem in the United States and the prevalence of obesity has risen more sharply among adolescents and young adults than among older adults. Alarmingly, obesity persists into adulthood for 70% of obese adolescents.118 Obesity has high health and financial costs, with roughly $100 billion per year spent on obesity-related health care.119 Because only 10% of children and adolescents actively seek weight loss treatment,120 primary prevention of excessive weight gain is essential.

A meta-analytic review of 64 obesity prevention program concluded that the overall effect of interventions was small.121 An estimated 21% of the programs produced significant preventive effects. The majority of the successful programs were those that were first evaluated in pilot trials rather than large demonstration trials. These were generally confined to pre- and post-intervention effects, so most had inadequate follow-up to evaluate the persistence of the effect. Successful programs were brief and solely targeted weight gain. Furthermore, effective programs focused on children and adolescents—especially females—rather than pre-adolescents. Programs that allowed participants to self select produced better outcomes.

Pediatric suicide

Suicide was the fourth leading cause of death among US 10- to 14-year-olds and the third leading cause of death among 15- to 19-year-olds in 2006.122 Approximately 2,000 US adolescents commit suicide each year. The rates of completed suicide are low, at 0.001% of children age 10 to 14 and 0.0082% among children age 15 to 19.122 The number for non-lethal suicide attempts is comparatively higher.

Risk factors for completed suicide include preexisting psychiatric disorders and stressful life events. More than 90% of adolescents who commit suicide have a psychiatric disorder.123 Stressful events may be biologic, social, and psychological in nature, including poor academic performance, physical or romantic loss, and family conflicts.123 TABLE 4 describes the modifiable and nonmodifiable risk factors and possible interventions to prevent suicide among children and adolescents.

The goals of suicide prevention programs are rigorous identification of potential cases, referral for mental health evaluation, and risk factor reduction.124,125 Programs have been implemented in schools, communities, and health care settings. We have considered these programs within the framework of universal, selective, and indicated prevention.


TABLE 4

Modifiable and nonmodifiable risk factors with possible interventions for suicide in children and adolescents

Modifiable factors Possible interventions Nonmodifiable factors
Preexisting psychiatric disorders/substance abuse Case finding
Referral and treatment of underlying depression/psychiatric problems
School-wide screenings
Primary care physician education and training
Previous suicide attempts
Family history of suicide
Stressful life events Crisis hotlines
Crisis services
 
Problems in school
Problems in family
Problems with the law
Skills training
School psychologist training
 
Access to lethal means Limiting access to fire arms/drugs/under-age drinking by appropriate legal means
Constructing barriers at jumping sites
 
‘Suicide contagion’ Educating media professionals  

Universal prevention programs.

School-Based Programs. Some schools integrate suicidal behavior awareness in standard curricula in order to encourage self-disclosure and help teenagers identify at-risk peers.126 The rationale underlying these programs is that teenagers are more likely to turn to peers than adults for support in dealing with suicidal thoughts.126-128 Several studies have reported positive outcomes from school-based programs of this nature.126,129-131 However, some reports suggest that open classroom discussion about suicide may be iatrogenic, influencing at-risk children to take suicidal actions.132-134 Research has shown that baseline knowledge about suicide is generally high126,132 and that knowledge alone may be insufficient to change behavior.133,135 Thus, new programs concentrate on treating the psychiatric conditions that predispose children to suicide.135

Some school-based programs seek to develop cognitive, problem-solving, and coping skills in suicidal children.136-138 By reducing internalizing and externalizing behaviors, these interventions produce benefits beyond reducing suicidal ideation.

Access Prevention. Children who have attempted suicide report ambivalence about dying, and many suicide attempts are the result of a transient impulse.139,140 Therefore, 1 universal preventive strategy is to reduce access to lethal means of suicide, such as firearms, pesticides, domestic gas, analgesics, or barbiturates. Similarly, raising the minimum drinking age and constructing barriers at jumping sites are measures that would impede suicide attempts.141,123

Media Education. Media can play a positive role in public education about awareness of suicide and its risk factors. However, undue publicity of suicide may also lead to “suicide contagion.”135 Health care providers can educate media professionals about this effect as a means of universal prevention.

Selective prevention programs. Children and adolescents with comorbid psychiatric illnesses and substance use disorders are targets for selective prevention programs. Suicidal individuals have regular contact with health care professionals: as many as 66% of suicide victims saw their physician in the month before their death.139,141 Yet comorbid psychiatric disorders in suicidal individuals are underrecognized and undertreated, particularly in primary care settings.

Adequate education and training of general practice and primary care physicians in suicide prevention are crucial. Studies in Sweden, Hungary, Japan, Germany, and Slovenia have shown that with training, physicians are able to identify and refer more patients to psychiatric treatment, thereby achieving a significant reduction in the rate of completed suicides.142 Suicidal individuals may be identified in school-based screening for comorbid psychiatric disorder, including depression, substance use, and recent or past suicidal ideations/attempts. The sensitivity for screening ranged from 83% to 100%, while the specificities ranged from 51% to 76%.143-145

Indicated prevention programs focus on screening high-risk children and adolescents for suicidal thoughts or intentions and guiding them to treatment. High-risk individuals may be identified using American Psychiatric Association practice guidelines for the assessment and management of suicidal patients. According to these guidelines, risk factors include previous suicide attempts, family history of suicide, aggressive or impulsive traits, comorbid cluster B personality disorders, smoking, substance use, and comorbid depression.146 Screening and treatment methods include:

  1. Self-report tools and individual interviews to identify children at risk for suicidal behavior.143-145,147

  2. School-based screening for suicidal thoughts, attempts, or behavior, or risk factors such as depression, aggression, and substance use.143-145 Such screening methods have proven to be reliable and valid for identifying individuals who are at increased risk of suicide.

  3. Training family practitioners, pediatricians, school counselors, psychologists, and gatekeepers to identify at-risk children and refer them for further evaluation and treatment.148-149

  4. Peer helpers. Suicidal children confide more easily in a peer or friend than an adult.126 Through school-based training, students were better able to identify suicidal peers, provide support, and assist them to seek appropriate help.

  5. Crisis hotlines that provide convenient, accessible, immediate support during a crisis. The rationale for hot-lines150-152 is that suicidal behavior often is associated with a crisis.153-157

Early-onset schizophrenia

Evolving interest in the early psychosis paradigm has lead to a focus on early detection and optimal treatment of first-episode psychosis.158 Häfner et al159 state that psychotic illnesses have clinical and social consequences near puberty, throughout adolescence, and into early adulthood. Primary prevention of early- and adult-onset schizophrenia is highly desirable, but there are no widely accepted causal factors that can be directly targeted for prevention. Current research is investigating genetic factors rather than clinical prevention.160,161

In family members of individuals with schizophrenia,162,163 the presence of certain biologic markers (eg, increased P300 latency and reduced amplitude) and neuropsychological features (eg, decreases in sustained attention, perceptual motor speed, concept formation, and abstraction) could be associated with phenotypic expression of symptoms of schizophrenia.164 In this section we briefly describe a schizophrenia prevention program available to adolescents.

Indicated intervention program. The Personal Assessment and Crisis Evaluation (PACE)158-167 clinic targets high-risk individuals, including adolescents and those at genetic risk who exhibit pre-psychotic features. The program provides psychosocial treatments aimed at managing stress and enhancing coping through problem solving and individualized case management.168,169

Use of cognitive therapy in preventing psychosis in high-risk individuals also shows promise.170 Orygen Youth Health, established in Melbourne, Australia, addresses the divide between pediatric and adult mental health services and recognizes the special needs of youths.158

Use of medications in the primary prevention of schizophrenia remains controversial and needs further research to assess the benefits and risks. Based on data that suggest a higher incidence of obstetric complications in the mothers of children who are eventually diagnosed with schizophrenia, Compton recommends universal and selective interventions to optimize pre-pregnancy and prenatal care, including nutritional interventions and providing vaccines before pregnancy.171-176 Just as symptom remission is a principle treatment goal for symptomatic schizophrenia,177 preventing conversion from prodrome to diagnosable disease is essential for at-risk adolescents. Additional information about prodromal schizophrenia and preventive strategies are provided elsewhere in this issue.

  CONCLUSIONS

Preventive programs have demonstrated some positive results among all age groups and mental health disorders. A review of the literature provides ample evidence to conclude that primary preventive interventions can be effective for preventing psychopathology and promoting positive development, particularly in high-risk children and adolescents. Most importantly, they can create awareness among children, improve understanding of mental illness, and enhance coping skills. Additional research is needed to further investigate the utility of various preventive approaches and to understand their lifetime impact on positive mental health.

Future directions

Environmental contexts. Preventive programs are more effective when they take children’s social environment into consideration. Rather than isolating the child as the target, programs should include a role for the family, school, peers, community, and neighborhood. These social factors have a strong influence on the overall mental health of a child, warranting a more holistic approach that targets multiple domains of a child’s environment.

Earlier interventions. Although effective across many age groups, most of the programs described in this article are more effective if applied at earlier ages, such as during preschool and elementary school. Such efforts can be supplemented in the form of “booster doses” later in life. Booster programs that address a child’s needs as he or she develops can provide ongoing support and better outcomes.

High-risk focus. It is feasible and cost effective to target multiple high-risk behaviors. Preventive programs are best directed toward risk or protective factors affecting the syndrome, rather than targeting a single problematic symptom. It is essential that these preventive measures be coordinated and integrated with other community care programs.

Systematic research efforts. Well-designed, blinded, controlled trials with long-term follow-up are needed to further investigate the utility and replicability of these programs.

Integration within/between systems of care. A very critical and important aspect is to integrate these preventive measures with other primary care systems to increase cost effectiveness and access. In the current environment of limited resources, a more comprehensive and coordinated approach is warranted.

A systematic approach taking into consideration all the previously mentioned factors would improve the prevailing system which is fragmented into local, municipal, state, and federal efforts. A coordinated approach, integrated with primary care would maximize the effectiveness and benefits of these programs.

ACKNOWLEDGEMENTS: This study was not funded by any agencies. The authors report no conflicts of interest in connection with the preparation of this manuscript.

DISCLOSURES: The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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CORRESPONDENCE: Subramoniam Madhusoodanan, MD, St. John’s Episcopal Hospital, Department of Psychiatry, 327 Beach 19th Street, Far Rockaway, NY 11691 USA, E-MAIL: sdanan@ehs.org