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

Categories: ChildhoodDisorders