Overlap with health promotion

Quite frequently 'prevention' is equated not just with primary or secondary prevention but extends into, or can be equated with, health promotion, a more positive and politically correct connotation. Yet notions of child and adolescent mental health, the subject to be promoted, can easily be viewed as idealistic. In the United Kingdom, an influential document from the Health Advisory Service cited a definition drawn up by Hill's group. (6)

Mental health in children and adolescents is indicated by:

• a capacity to enter into and sustain mutually satisfying personal relationships

• continuing progression of development

• an ability to play and learn so that attainments are appropriate for age and intellectual level

• a developing moral sense of right and wrong

• the degree of psychological distress and maladaptive behaviour being within normal limits for the child's age and context.

This definition could reasonably be criticized as being utopian and expansive. It is apparent that no absolute boundaries between mental health and moral or spiritual well being exist without much cultural qualification. It is also broadly equivalent to promoting normal psychological development. Some child psychiatric disorder is reasonably conceptualized as arising from developmental distortion or arrest, but by no means all. In other words, mental health promotion based on promoting development will be incomplete.

A different emphasis may be complementary—that child and adolescent mental health is a commodity.(7) A mentally healthy child has enough of it to cope with adversity. Such a child has enough of a capacity for relationships, enough defences against overwhelming emotions or cognitions, and enough self-esteem to withstand unpleasant life events or recover promptly from them. Health becomes not just the absence of disease but resilience. One views a child who has been exposed to adversity and survived, perhaps even having been steeled by it, as healthier than one who develops maladaptive behaviours or negative emotional states. Yet little is known as to what components of resilience can be promoted in worthwhile efforts. There are clues, but it is early days. Some of the components of resilience, such as high intelligence, cannot obviously be taught, though others such as high self-esteem and a repertoire of coping strategies are learned, particularly within the family of origin.

Evidently, ideas about mental health derive from ideas about physical health and these are themselves somewhat hazy. Whichever view is taken, it is apparent that child and adolescent mental health promotion is linked closely with socialization, and particularly the quality of parenting and education. Most primary prevention programmes have sought to build parenting skills and provide supplementary education for children. Some of these programmes have been tested on areas of functioning that are not narrowly to do with mental health but are social—law-breaking and aggressive behaviour, educational achievement, and so forth.

It is also clear that distinctions between promotion and prevention are ones of emphasis, and there seems no good reason for forcing a distinction. The firmest conclusion that can be drawn from the above is that any consideration of services for a population has to be not just reactive to problems but orientated to the future, a requirement for a prospective perspective. With this in mind, several principles have become clear from recent work. Here, the familiar term of primary prevention has been retained for the sake of clarity, the above criticisms notwithstanding.

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