Choosing between universal and targeted approaches

Thinking about prevention often starts with analogies with immunization programmes for young children. Yet it has long been considered that this is an inappropriate example for child mental health. Several authorities (9,1°) conclude that there is evidence for the superiority of 'nutritional' programmes (malnutrition analogy) over 'inoculation' programmes (immunization analogy). In particular, input needs to be sustained and tailored to the child's developmental level. (10) But if one takes a 'nutritional' approach, such as parent management training, how might it be made to work?

Given the association between child psychiatric disorder and social disadvantage, it might be thought that it would make sense to give priority to socially disadvantaged families. Yet these are a small minority in the general population and the overall effect on general population rates would be small. This is Rose's (H) paradox: although conduct disorder, for instance, is more common in social class V, there are more cases in social class III because this is a larger group. It is also the case that socially disadvantaged families tend to be overwhelmed, alienated, and demoralized so that a variant of the inverse care law also applies: those at highest risk are those least likely to participate. Rather similarly, prevention programmes using cognitive techniques can reduce subsequent depressive disorder in adolescents with a large number of premorbid depressive symptoms. However, if these are targeted as high-risk individuals, then most cases of subsequent depression will be missed since these arise in adolescents with low premorbid symptom counts.(5)

Therefore a universal (whole-population) approach should produce a greater reduction in rate. Yet it is less likely to be effective if it requires attitudinal or behavioural change in most people, since their motivation to participate is less if they perceive their own individual risk to be small; an intervention that produces substantial benefits to the community is likely to confer limited benefit to the individual. Individuals or families in the wider population are unlikely to participate in a prevention programme that offers them little gain, even if it will benefit some other members of the same population.

Some universal approaches may not require opting in. Major changes in social values so that, for instance, continuity of parenting is promoted, emotional abuse readily recognized and deprecated, or open intrafamilial discord proscribed might lead to improved child mental health. These particular values relate to known pathogenic processes. This is important since an unthinking attempt to change social risk factors may be ineffective unless the intervening processes are known (see below).

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