It’s difficult
to argue with the kind of homespun but commonsense wisdom most of us grew up
with that “An ounce of prevention is better than a pound of cure”, and “A
stitch in time saves nine”. The veracity of such claims declares itself to us
time and time again in many mundane experiences of everyday life and has also been
borne out in all kinds of ways in relation to population health. Talk to people
who lived through the poliomyelitis epidemics of the 1930s, ‘40s and ‘50s, and
I doubt you will meet many gainsayers when it comes to the benefit of mass
vaccination programs. Although there are unfortunately continued pockets of
resistance to population-based vaccination programs, most people would agree that
these, along with significant improvements in sanitation, refrigeration and
water quality, have gone a long way to reducing, if not eradicating diseases
that were the scourge of earlier decades and produced high rates of morbidity
and mortality. Of course we maintain
secondary and tertiary treatment services for circumstances where
once-eliminated diseases re-surface (e.g. the increase in Australia of tuberculosis
notifications in recent years), but in general, the public health model
pertaining to biomedical illnesses is one that affirms those axioms we all
learned at our mother’s knee.
The situation
pertaining to psychosocial distress is not nearly so clear-cut however. Here,
we are not seeking to isolate under a microscope a single rogue organism for
which prevention and/or treatment can be developed through years of painstaking
laboratory-based research. The ecology of human societies is far more complex
than anything a lab scientist will observe on a glass plate. This doesn’t mean
of course that we can’t extrapolate some useful models from biomedicine, but it
does mean we need to do so with care, particularly when we are tackling
such complex phenomena as child maltreatment, youth offending, academic
under-achievement, mental illness, and substance abuse. Complex outcomes have
even more complex inputs, and many of these are heavily influenced by the social gradient in health and well-being.
Now I’m certainly not
about to disagree with the World
Bank when it asserts that
Early interventions yield higher returns
as a preventive measure compared with remedial services later in life. Policies
that seek to remedy deficits incurred in the early years are much more costly
than initial investments in the early years. Nobel Laureate Heckman (1999)
argues that investments in children bring a higher rate of return than
investments in low-skill adults.
Heckman and Carneiro's modelling on
human capital policy (see graphic depiction below) has obvious face validity: skew childhood investment (health, education, welfare etc) towards the
first five years of life, and reap the rewards down the track. Oh that it was
so simple!
Image source: http://www.successby6edmonton.info/development/
In reality, efforts to invest public funds in large scale “front end” interventions
(e.g. Sure Start in the UK, Head Start in
the USA and Pathways
to Prevention in Australia) have had some success, but not on the scale that we associate with mass
vaccination programs. This shouldn’t surprise us of course – there are many
more “moving parts” when it comes to intervening in real time in the lives of
communities, pre-schools, schools and families, and it is enormously difficult
to ensure that these programs are delivered with appropriate intensity and fidelity
(i.e. according to the principles and practices outlined by those who developed
them). There is also a notorious problem with long-term follow-up on
participants in early intervention / prevention programs – because follow-up is expensive to
do over more than the short-term, and because politicians and the public tend
to be impatient for a “quick fix”. Absence of evidence of a quick fix can (erroneously) be taken to mean evidence of lack of an effect. Further, it can be difficult over long periods,
to establish cause and effect relationships, given that some external
influences (e.g. a country’s economy and political climate) are not under control of the researchers.
However there is
another problem if we focus too exclusively on prevention and early intervention, and that is
the question of how we respond to the needs of those vulnerable young people
who will inevitably fall through holes in the net of even the best prevention / early
intervention programs. Here, I am thinking particularly of young people who
wind up in the youth justice system, in many cases via initial involvement with
child protection services. Such young people will have almost certainly
experienced complex trauma, early educational departure (and
under-achievement), have emotional and behavioural difficulties, and minimal
life / vocational skills. Some (though not all) will have diagnosable neuro-developmental difficulties, such as autism spectrum disorders, language-learning problems, and foetal alcohol syndrome. Their "failure to thrive" is a sad but almost inevitable reflection of inadequacies in the systems around them - systems that are meant to afford predictability, protection, and optimism but too often are fragmented, under-funded, and not informed by "joined-up thinking".
Does neuroscience research afford any hope?
If all of this
sounds very depressing (which in many cases it is), then perhaps we should turn
to recent developments in neuroscience for some inspiration. When I was an
undergraduate student (admittedly a few summers ago), the prevailing wisdom was
that the human brain has finished its development by around age 18. Given that
I was probably around 18 myself at the time, I thought that sounded perfectly
reasonable and accepted this “fact” without question. However, we only need to look
as far as road trauma statistics to see that 18 is not the end of the story for brain development, even though brain growth at a macro level, may come to an
end when the skeleton has stopped growing in late adolescence.
In Australia, as
in many other nations, young drivers have stringent restrictions placed on
their driver’s license in the first three years on the road. Why? Because their
significant over-representation in road trauma statistics reflects the fact
that their pre-frontal regions (brain areas responsible for higher-order, “executive”
functions such as paying attention, planning, organising, assessing risk,
curbing impulsivity, etc) are still 5-7 years away from their final
maturation. If you are not familiar with
this research, then have a look at the National
Academy of Science (USA).
We now
understand that the high-point of grey matter (cell bodies and axons) volume in the brain occurs during early adolescence, after which
there is a process of “synaptic pruning” to remove inefficient synapses and
strengthen those that are “exercised” by experience (whether positive or
negative).
[Source unknown – I would be grateful to anyone who can
enlighten me, so I can provide appropriate acknowledgement].
So – what does
this have to do with vulnerable young people and how we spend our prevention and early intervention
dollars?
Perhaps we need to be thinking more about the untapped potential of
the still very under-developed pre-frontal regions of an incarcerated 16 year
old’s brain, rather than assuming that “the horse has bolted” and consigning
this young person to the margins of society. Of course we don’t deliberately seek
such outcomes, but the state is not always a good “parent” and sadly the
outcomes of state intervention in young people’s lives are often far from
acceptable.
Being on the margins of society is not only bad for the young
person, but also creates additional social and economic burden for everyone
else. Marginalised young people will need public housing, social service benefits,
vocational training (which in many cases will not lead to sustained employment),
and a myriad of related expensive health and welfare services - over many years.
If the developing brain does not, even under ideal circumstances, resemble that of an
adult’s until the early to mid 20s, why would we “give up” on teenagers who are
clearly developmentally vulnerable?
Research (e.g. see the National Child
Trauma Academy) on the neurobiological consequences of early
maltreatment (abuse and/or neglect) tells us that such experiences become part
of the brain’s “architecture”, creating neural pathways supporting responses such
hyper-vigilance to threat, that may be functional in some circumstances (e.g. in a
chaotic, unsafe home environment), but highly dysfunctional in others (e.g. at school). Surely this neuroscience should be just as exciting in relation to vulnerable young people as it is with respect to our understanding of typical development?
It’s been said
that a barrister should never pose a question in court to which he or she does
not already know the answer. Happily however, it's the role of academics to do just that. I am not sure how much the neuroscience evidence on the adolescent brain can inform our approach to interventions for vulnerable young people. I also don't see "neuroscience" per se as a holy grail - it's simply a tool that provides some helpful information. However I am concerned that policy makers and practitioners don't assume an
overly pessimistic stance with respect to the capacity of vulnerable young
people to benefit from therapeutic and educational services that are offered
after they have disengaged from formal schooling and have been involved with
youth justice and child protection.
The caveat of course, is that these
services must be designed and delivered by skilled practitioners in accordance
with developmental (and trauma-informed) principles and will almost certainly need to be
offered over a period of years,
rather than mere months. Neural pathways that are inevitably being formed and
shaped in this time need to be developing in response to predominantly
positive, functional and adaptive experiences. Approaches such as Multisystemic therapy offer some hope, but are neither widely
available nor subject to quarantined funding. Programs such as Take Two are also ones to watch over time. Methodological challenges in assessing efficacy / effectiveness are many and need to be tackled with great care.
At the very least, we need to
work more assiduously to bring policy makers and practitioners from education,
welfare, justice, child protection, vocational training and mental health
services to the one table, to identify ways of capitalising on the otherwise lost
decade of brain maturation that occurs for all young people between 15 and 25 - not just for those who are part of the thriving mainstream.
(c) Pamela Snow 2014
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