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prevention in child and adolescent psychiatry

Bhatia, Richa

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doi: 10.1097/YCO.0000000000000553
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This section touches on a few vital facets of child and adolescent psychiatry, namely attachment, early life stress, mental health disparities and youth suicide.

The development of secure attachment is a key task in infancy and early childhood. The type of attachment impacts not only a child's mental health but also has an enduring effect on interpersonal relationships, emotional regulation skills, cognition and neurobiology through adulthood [1]. Therefore, programs and interventions facilitating the development of optimal attachment warrant special emphasis in preventive psychiatry. In their article -- ‘Preventive parent-young child interaction interventions to promote optimal attachment’, authors Tereno et al. (pp. 542–548) shed light on various early intervention programs that focus on enhancing infant secure attachment and reducing the likelihood of disorganized attachment. The programs discussed in this article, primarily target parent--infant/young child interactional experiences, maternal sensitivity and parental disruptive behavior, in addition to a few programs that examine paternal engagement with the infant and/or the parental relationship. Steps Toward Effective Enjoyable Parenting (STEEP), Circle of Security Intervention (COS), Minding the Baby (MTB), Video-Feedback Intervention to Promote Positive Parenting are some of the recent early intervention programs reviewed in this article.

Implementing interventions early in life and specially addressing high-risk/multirisk families can benefit secure attachment development. The authors found that secure attachment may be enhanced through promoting maternal sensitivity and that early interventions can reduce the likelihood of disorganized infant attachment through a reduction in maternal disruptive behavior. Although maltreatment by the parent/primary caregiver often underlies infant disorganized attachment, it is worth noting that infant disorganized attachment can result even when the parent/primary caregiver is nonabusive, but, exhibits ‘frightening, frightened’ or even slightly dissociated behavior towards the infant [2]. These, often subtle, parental behaviors can occur if the parent has ‘unresolved trauma or loss’ or is experiencing acute adversity/crises and related stress dysregulation [2]. This review also indicates how future research should explore and examine the pathways underlying the shift observed with such interventions, so that interventions can be fine-tuned and further targeted to increase the development of secure attachment.

The article on ‘Early Life Stress: Update on Neurophysiologic Effects and Treatment’ by Zik and Berkowitz (pp. 528–533), reviews recent updates on the effects of early life stress (ELS) on neurotransmission and on neuroendocrine, epigenetic, and immune systems from childhood through adulthood. This review highlights the need for early and preventive intervention, given the various functional and often enduring negative effects that ELS has been known to inflict on multiple organ systems and on emotional well being throughout life.

The authors provide an intriguing review of the various effects of ELS on the rein–angiotensin–aldosterone system, hypothalamic-pituitary-gonadal axis, telomere length, cortisol reactivity, epigenetics, and on inflammatory markers such as C-reactive protein via epigenetic pathways. Further research is needed to gain a better understanding of nuances of these relationships. In addition, this review discusses certain sex-specific differences in the neuroendocrine effects and manifestations of stress between male and female individuals. For instance, decreased cortisol reactivity has been found in female children with ELS, in contrast to elevated cortisol reactivity seen in male children, in response to a stressful task. Not only that, sex-specific epigenetic differences have been noted in infant attachment as well as in telomere length, in the context of ELS.

The authors highlight the need for increasing training and integration of trauma-informed care as well as behavioral health into primary care to increase identification and treatment of families at risk for ELS. Early parenting-based programs can be beneficial in achieving positive outcomes, given their potential to impact crucial neuroplastic periods of a child's life. The authors discuss recent online treatment interventions, such as LIFT (Life Improvement for Teens) and Bounce Back Now, that have been developed for adolescents, and recommend the use of technology to build more novel, innovative treatment delivery methods. The authors also underscore the need for research that identifies the age at which stressors occur, to further our understanding of specific target periods so that suitable interventions can be developed accordingly. Also, research examining sex-specific differences in response to ELS and pathways mediating these differences, can help in developing more nuanced and effective treatment strategies.

Despite the multitude of healthcare advances worldwide, healthcare disparities abound globally. These disparities are even starker in the case of mental health, and serve as a barrier, often keeping at risk children, youth and parents from accessing and receiving much needed treatment. There is presently a dearth of research examining various aspects of mental health disparities affecting children and adolescents in indigenous communities around the world, and more research is needed to facilitate creation and implementation of suitable, targeted approaches to address these disparities. The review article, ‘Mental health disparities, mechanisms, and intervention strategies: perspective from Hawai‘i’ by Geurrero and his team, focuses on mental health disparities among children and adolescents, drawing particular attention to the mental healthcare disparities affecting Native Hawaiian children and youth, and the special approaches that have proven to be of benefit in ameliorating these disparities. The authors discuss how Native Hawaiians, not dissimilar to several other indigenous populations around the world, experience much greater mental health disparities because of socioeconomic--geographic disadvantage, stigma, cultural and/or language barriers, shortage of mental health resources, history of trauma and other factors.

The authors emphasize that preventive efforts and interventions aimed at addressing mental health disparities need to be culturally informed, developmentally attuned and culturally affirming. In addition, these interventions should be made available in a variety of settings where children and parents are most likely to first present. This review finds that a strength-based approach that celebrates and promotes a positive cultural identity, emphasizes family, community and connectedness and tailors best practices to suit community and cultural needs, can be beneficial in improving treatment outcomes for Native Hawaiian youth. In addition to other measures, the authors recommend utilization of community-based patient navigators to decrease obstacles to accessing and receiving mental healthcare. It is possible that novel, evidence-based interventions implemented in one community may serve as a springboard for developing, adapting and/or fine-tuning similar interventions for other populations suffering from the adverse effects of such disparities. Hence, further research in this arena is recommended.

One of the major advances in the world in the last two decades or so has been the use of internet. In the last several years, internet use has burgeoned, while research on the effects of internet use on childhood mental health has not kept up with this tremendous expansion. Given how internet use has become pervasive and extensive for millions of youth, we cannot afford to ignore its potential effects on mental health, specifically on suicide risk. Suicide is one of the leading causes of death among children and adolescents worldwide, and effective identification techniques and prevention tools are lacking. It is urgent and imperative to develop, implement and examine strategies for identification of at-risk youth. In their review article titled ‘Social media, internet use and suicide attempts in adolescents’, authors Sedgwick and team (pp. 534–541), discuss recent research examining the link between social media/internet use and suicide attempts among adolescents. So far, there has been a scarcity of research reviewing this association.

Through their review, which included a total of 346 416 youth less than 18 years of age in different countries, the authors found an independent link between heavy or ‘problematic’ internet/social media use and suicide attempts. The authors highlight cyberbullying victimization as an important aspect that was found to be a confounding factor in some studies. Cyberbullying needs further research and intervention efforts, particularly, given its links with suicidality. In this review, the authors also discuss the potential positive impact of internet use for adolescents, particularly through offering a mode of support and interaction. There is a scope for further development of avenues through which the internet can be utilized to detect and identify vulnerable youth and those at risk for suicide. The authors point out to the use of internet search data as being one such potential avenue. Further research examining nuances of internet usage among youth and its correlation with suicide attempts can go a long way in creating tools to utilize internet as a platform for enhancing support for youth as well as decreasing suicide risk. One of the limitations of this review, as noted by the authors, was the variegated manner in which social media/internet use has been described in existing research.

A salient, overarching theme in this section is the focus on prevention and early intervention via bettering our understanding of various intricacies inherent in these subjects. These review articles are aimed at increasing awareness and knowledge of recent findings for consideration in practice where appropriate and applicable, as well as to guide future directions for research.



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Conflicts of interest

There are no conflicts of interest.


1. Walsh E, Blake Y, Donati A, et al. Early secure attachment as a protective factor against later cognitive decline and dementia. Front Aging Neurosci 2019; 11:161.
2. Granqvist P, Sroufe LA, Dozier M, et al. Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers. Attach Hum Dev 2017; 19:534–558.
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