Sunday, 5 January 2014

Prevention? Yes please...but not at the expense of 1:1 services for those who need them


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!

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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