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PREVENTIVE PSYCHIATRY IN INDIA

PREVENTING ON CHILD PSYCHIATRIC FRONT

Devashish Konar MDDirector & Consultant Psychiatrist, Mental Health Care Centre, Kolkata & BurdwanPresented in ANCIPS 2017, Raipur

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PREAMBLE

Most of the psychiatric illnesses have multifactorial etiology. Strategy to prevent them is not an easy task. With meagre resources Indian landscape seems next to impossible to penetrate and yet we should act. Area needs attention because even small dent made will have huge impact.

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SOME GLARING DATA !• In the World Health Organization’s World Health Report 2001 it was pointed

out that psychiatric disorders ranked as 5 of the top 10 causes of disability in the global population.• Studies specifically of psychiatric disorders in children report that between 3

percent and 18 percent of children have a clinically significant psychiatric disorder, a number far exceeding those with access to treatment.• A recent study which included data on age of onset found that 50 percent of

psychiatric disorders had their onset by age 14, and 75 percent by age 24. • Treatment on this scale is unlikely to be feasible in foreseeable future, even if

available methods were more effective and less risky than those currently available.

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THE RATIONALE OF TAKING NOTE

• Research demonstrates that first symptoms of behavioural problems typically precede a mental, emotional or behavioural disorder by two to four years and that early therapeutic intervention can be highly effective at limiting the severity and/or progression of problems.• Prevention and early intervention is defined as any activity which is aimed at

identifying and/or treating risk factors for early symptoms of emotional and behavioural disturbance that may lead to mental illness. Some amount of input in the field of preventive psychiatry is bound to bear fruits.

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PREVENTION APPROACHESAs Proposed by the Chronic Disease Commission in 1957

• Primary prevention encompasses preventing mental health problems

before they occur.

• Secondary prevention involves minimizing or correcting the course of

a problem once it has begun to manifest.

• Tertiary prevention aims to soften the impact of an illness that has

lasting effects.

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WHERE AND HOW TO INTERVENE ?Introduced by Gordon in 1983

Disseminated through the seminal Institute of Medicine report in 1994

• Promotion• Prevention

- Universal Prevention: Provided to entire populations or the general public

- Selective Prevention: focuses on groups identified as at heightened risk of developing mental health problems.

- Indicated Prevention: targets people ‘who are identified as having minimal but detectable signs and symptoms foreshadowing mental

disorder. • Early intervention• Relapse prevention

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HEALTH PROMOTION• General measures for health promotion include improving nutrition, housing, access

to education and economic security.• Some other issues are strengthening community networks, reducing exposure to

violence, decreasing substance abuse, and intervention to help with recovery from disasters. • Risks for children’s mental health from the proximal family environment include

adverse maternal behavior during pregnancy, such as substance abuse, child abuse, parental mental illness, and domestic violence.• These may be addressed with measures such as home-visiting programmes for

pregnant women and new mothers and pre-school programmes.• ASHA (Accredited Social Health Activist), ANM (Auxiliary Nurse Midwife) and AWW

(Anganwadi Worker) can do wonders if they are sensitized and trained.

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ACT EARLY !

Mental health problems experienced by infants and families during the perinatal period are a major public health concern as they can have serious, long-lasting and potentially intergenerational consequences.

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PREVENTING ON CHILD PSYCHIATRIC FRONT:

• Parenting training of would-be-parents, early detection of vulnerable children and timely intervention are some of the efforts that will give large dividend. • We have very limited number of child psychiatrists. So

including general psychiatrists, pediatricians, family physicians, health workers and teachers would be the most suited public health strategy for India. • They need to be trained to work within their limits and need

to learn to refer at the right time without wasting precious time of the growing children and adolescents.

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PARENTING AS AN IMPORTANT STRATEGY

Best environment meets needs of least distressed child.

Worst environment cannot meet needs of healthy, easy going child.

• Love, Care and Commitment• Control / Consistent Limit Setting• Facilitation of Development

‘good enough parenting’???

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MENTAL HEALTH TRAJECTORIESOUTCOMES OF PSYCHOLOGICAL PROBLEMS OF CHILDREN:

Education and Income: Children with emotional disturbance are more likely to have academic problem, have the highest school dropout rates, lower educational attainment and lower income.

Crime: Children with some mental health conditions – Including ADHD, early aggression and behavioral problems – are at greater risk for later criminal behavior.

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LESSONS FROM ADVANCES AND TREATMENT• Early intervention may be important because there may be critical periods when

the developing brain is relatively more plastic and thus offers more opportunity for change.• For many mental disorders, however, we don’t know whether such a critical

window of opportunity exists. We are increasingly finding evidence that our programmes can help at later ages as well. • Approaches have to be tiered that provide interventions to entire at-risk

communities of children and then focus additional services on high-need families.

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MENTAL HEALTH INTERVENTIONS Healthcare Interventions Academic Interventions Social Agencies Interventions

Delinquency and Juvenile-Justice Interventions

Child mental health is a serious public health and social problem, yet our interventions are notable for their lack of cohesiveness. Mental health disorders can affect children at different ages and can be detected and treated in health-care settings, schools, social agencies and even juvenile justice system. Divided system responsibilities for children make it difficult to deliver prevention programs.

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PREVENTIVE MEASURES

• Mother’s and Father’s age• During pregnancy

-Maternal Nutrition -Smoking, alcohol and exposure to other substance abuse

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YOU NEED DIFFERENT KINDS OF PREVENTION PROGRAMME

• Children’s emotional attachments are established in their very early years.• IQ appears to stabilize by age 10.• Adolescence is both a critical period of risk-taking and potential substance use

and a period of potential intervention because portions of the adolescent brain are still plastic.• Not surprisingly, therefore, prevention programmes’ emphasis depends on a

child’s age.

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GOOD EXAMPLES OF PREVENTIVE PROGRAMME ACROSS THE WORLD FROM WHERE WE CAN LEARN

• Mental health consultation for both parents and children• Head start• Incredible years training• Prevention of substance abuse

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CHILD MALTREATMENT PREVENTION: POSSIBLE

APPROACHES• Education• Support Groups• Home Visit• Community Programmes and Broad Public Policies• Individual or Family Therapy

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BE INCLUSIVE

• Improve partnerships with education, child protection, family court, correction homes, allied health practitioners and existing providers who have community networks for family in need.• Build work force. Enhance the skill of the trained. Train the

motivated untrained.• Organise interaction meetings of all concerned to have an idea of

greater landscape.

No one person or profession has or can have all the knowledge or skills.

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STRATIFY TO SUCCEED

• Parenthood preparation (before conception)• Perinatal and Infant (conception to two years)• Preschool (two to five years)• School age (five to 12 years)• Adolescence (13 to 18 years)

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SPECIFIC PREVENTIVE INTERVENTIONS FOR BEHAVIORAL PROBLEMS AND PSYCHIATRIC DISORDERS

• Divorce as a risk factor for Psychiatric Disorders• Conduct Disorders and Aggressive Behavior• Depressive Disorders• Psychotic Illnesses

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SOME OBSERVATIONS• Universal prevention programme with evidence of benefit have been

developed for issues such as conduct disorder, anxiety, and depression. • These have been primarily school-based, focusing on classroom

behavioural management, social skills training, and cognitive strategies to help children learn prosocial behaviours and cope with stressful situations.• Some programmes adopt a multimodal approach which includes

parents.• Universal approaches to decrease substance abuse have mixed results.

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VULNERABLE GROUPS

• Financially and socially marginalised section• Children of parents with mental illness

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PUBLIC POLICY AS A STRATEGY FOR PREVENTION IN CHILD PSYCHIATRY

• Poverty alleviation• Neighbourhood unity• Quality of education• Play situations and other extra-curricular activities• Good housing• Employment of parents• Marital and family support• Accident prevention• Protection from abuse

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EPILOGUE

It is to be hoped that as our understanding of these disorders grows, public policies to prevent the development of mental health disorders in children will become as commonplace a responsibility for modern societies as the provision of clean drinking water.

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Thanks