New Insights into Prevention of Depression and Disruptive Behaviour Disorders in Childhood: Where Do We Go from Here?
MacMillan, Harriet L., Canadian Journal of Psychiatry
At a time when the burden of suffering related to children's mental health problems remains unacceptably high,1 this series provides new and important insights into approaches to preventing 2 of the most serious and common psychiatric conditions in childhood: depression2 and disruptive behaviour disorders (DBD).3 This information is of major relevance to people working not only in the field of children's mental health but also in the field of adult health; both conditions can lead to long-term impairment extending into adulthood. Further, many adults with psychiatric disorders are parents whose conditions may place their children at risk for either depression or DBD. Knowledge about preventing childhood disorders is important for all mental health professionals.
Both In Review articles consider the evidence for prevention using the Institute of Medicine framework4 that classifies interventions based on the intended population:
1. universal - all residents in a geographic area as large as a country or as small as a school, regardless of risk;
2. selective - members of a subgroup considered at high risk for a specific outcome(s); and
3. indicated - people with subclinical symptoms or signs of a disorder.
As the authors of both reviews highlight, it is not simply a case of what prevention approach works, but what works for whom and under what conditions?
In their In Review article, Dr Tracy RG Gladstone and Dr William R Beardslee2 conclude that there is reason to be hopeful about our ability to prevent depression in children and youth. However, they emphasize that while some interventions based on cognitive-behavioural and interpersonal models have been shown effective in reducing depressive symptoms, far fewer have demonstrated positive effects in preventing depressive disorders. Even in the trial of the Coping with Stress course,5 where there was a statistically significant reduction in diagnoses of depression among the intervention group, compared with control subjects, the size of the effect diminished over time. Of particular note for policy makers hoping to intervene at the population level, selective and indicated approaches appear to be more effective than universal programs. It is essential when disseminating a program that the actual sample for whom the intervention was intended is the group who receives it; too often there is the misguided expectation that if a program is beneficial for some, it should be good for all.
Gladstone and Beardslee2 suggest that future studies should consider moderators of program effects, such as risk status, sex, and Stressors. They also recommend further consideration of interventions that improve the family environment, on the basis that adverse family circumstances are among the most consistent correlates for depression in youth. Clearly future trials assessing programs to prevent depressive disorders need to be sufficiently powered to address this outcome.
In their In Review article on DBD prevention, Dr Amélie Petitclerc and Dr Richard E Tremblay3 also found that few studies focused on prevention of actual disorders. Most efforts to prevent DBD have focused on parenting, or to a lesser extent, behavioural symptoms. Some interventions such as the Incredible Years BASIC Parent Training Program,6 which included parenting and DBD symptoms as outcomes, showed improvement in parenting behaviour, but no reduction in children's DBD symptoms. Among those few programs, such as the Nurse Family Partnership, that have targeted specific DBD problems, there were positive effects for prevention of risk factors and some associated outcomes, but not for reduction of actual DBD. As with depression programs, those interventions showing positive effects in preventing DBD symptoms were indicated or selected; the DBD review did not identify any universal programs effective in reducing DBD symptoms.
To move the field forward, Petitclerc and Tremblay3 emphasize the need to consider causal risk factors for DBD that can be identified during the perinatal and early infancy periods. …