Department of Preventive

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What longitudinal studies can tell about the life
chances of NZ youth
Professor Richie Poulton Director, Dunedin
Multidisciplinary Health and Development Research
Unit

• Department of Preventive Social Medicine
• Dunedin School of Medicine
• University of Otago

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Todays menu

• Which interventions maximise
• Choice?
• school readiness
• Capability?
• mental health problems including depression and
  suicide
• antisocial behaviour including domestic violence
  and child abuse
• teen substance use including alcohol
• overweight and obesity.

Degustation menu

• Why is the prevention paradigm the only real way
  of creating choices and developing capability?

• Identifying the key foci for intervention - a
  best bets approach
• guided by the empirical evidence-base and the
  potential for greatest return to society.

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New Zealands children need

• the ability to think clearly and quickly
• to be adaptable
• to be rid of debilitating mental health or
  emotional problems
• to be physically fit and not encumbered with
  chronic physical ailments and
• to be effective social beings, who do not violate
  the rights of others, or worse, harm their fellow
  citizens.

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Perhaps ironically
The most cutting-edge genetic research

• is the best advertisement I know of for
  importance of the environment!

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The question then becomes

• When do we intervene and
• with what
• to make the biggest difference?

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William Wordsworth (1770-1850)

• My heart leaps up when I behold
• A rainbow in the sky
• So was it when my life began
• So is it now I am a man
• So let it be when I shall grow old,
• Or let me die!
• The Child is father of the Man
• I could wish my days to be
• Bound each to each by natural piety.

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Gerard Manley Hopkins (1844-89)

• The Child is father to the man.
• How can he be? The words are wild.
• Suck any sense from that who can
• The child is father to the man.
• No what the poet did write ran,
• The man is father to the child.
• The child is father to the man!
• How can he be? The words are wild.

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What is the evidence base?

• The World Health Organisations burden of
  disease framework tells us that the three
  conditions associated with the greatest loss of
  life and productive years (i.e. living with a
  disability) are, in order

• cardiovascular disease
• cancer and
• mental health disorders.

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Mental health

• In 2003 we showed that among adults with a
  psychiatric disorder, 50 had had a psychiatric
  diagnosis by the age of 15, and three-quarters by
  age 18 (i.e. by the end of adolescence).
• Some have interpreted these findings to suggest
  that approximately half of all mental health
  disorders could be averted were we to intervene
  effectively during adolescence or earlier.

Kim-Cohen et al, Archives of General Psychiatry,
2003
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The take home message
Dealing with nascent or emerging mental health
problems effectively, early on, could reduce

• an enormous amount of suffering borne by both the
  individual and the community and
• a significant amount of lost productivity when
  viewed across the totality of a persons working
  life.

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Bad behaviour bad outcomes

• Antisocial behaviour that emerges early in life
  and persists over time is not only associated
  with
• poor mental health
• bad relationships and
• criminal behaviour in adulthood
• but also increased risk for a range of physical
  health problems
• Heart disease and stroke (x 3)
• Symptoms of chronic bronchitis (x 3)
• Gum disease (x 4)
• Herpes (x 2)
• Smoking (x 10)
• Injuries (x 4)
• High rates of hospitalisation (x3)

Odgers et al, Archives of General Psychiatry, 2007
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The roots of violence and abuse

• Most people do not realise that the child abuse
  and domestic violence we are concerned about does
  not usually arise de novo in adulthood.
• Our data, and that of others, show quite clearly
  that the lions share of these problems can be
  attributed to individuals who have been
  exhibiting antisocial traits from very early in
  their lives.

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Who to target?
The Dunedin study has arguably one of the most
detailed research programmes on antisocial
behaviour in the world.

• We have identified
• early-onset individuals whose behaviour persists
  throughout their lives (i.e. lifecourse
  persistent)
• as well as another larger group comprising about
  one-fifth of the population, who begin to engage
  in antisocial behaviour in adolescence.

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The implications for intervention

• Early onset life-course persistent group you
  need to intervene with both child and their
  family as early as possible
• Adolescent-onset group the worst thing you can
  do is use a group intervention approach, given
  that their behaviour is partly driven by peer
  influence individual interventions are required
  

NB Prison is a group intervention which tends to
expand rather than diminish the antisocial
repertoire.
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Substance use and abuse
After adjusting for differences in propensity to
use substances (using a sophisticated statistical
technique), early-exposed teens were at risk for

• adult substance dependency
• genital herpes
• early pregnancy
• school failure and
• criminal convictions

BUT
the majority of teens with no antisocial history
(65 of the cohort 50 of substance users) were
ALSO at an increased risk for poor health
outcomes following early substance exposure.
Odgers et al, under review
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Summing-up

• Together, research from the psychosocial domain
  clearly shows illustrate the benefits that would
  accrue by intervening early to reduce the
  significant burden associated with mental health
  problems, antisocial behaviour and teenage
  substance use.
• By addressing all three, the toxic effects on
  capability will be mitigated.

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What about physical health?
What else can we target?

• Overweight and obesity are a major public health
  problem.
• energy in energy out balance

For example, we have data under review showing
that the amount of sleep children had in their
first decade was as strongly related to
overweight by age-32 as self-reported physical
activity and diet at that age.
?
Landhuis et al, under review
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Interventions
To maximise choice by enhancing

• school readiness and
• capability by reducing psychosocial and physical
  impairment

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Enhancing school readiness
Social-emotional factors

• In order to learn in school, children need to be
  able to control their behaviour and their
  emotions.
• Self control is evident when children are
• low in aggression
• high in prosocial behaviours towards teachers and
  other children
• do not disrupt classroom activities and
• are cooperative and compliant with the teachers
  instructions.

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Cognitive Factors
Enhancing school readiness
In order to complete assignments and learn new
skills, children rely on basic memory and
attention processes.

• Working memory abilities help children hold new
  information in mind long enough to learn and to
  follow directions
• Attention abilities help them to focus on a task
  instead of becoming distracted by external
  stimuli.
• Attention abilities also help children to inhibit
  inappropriate responses, such as talking out of
  turn.

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Language Factors
Enhancing school readiness
Strong language abilities are essential for
successful reading.

• First, children with richer vocabularies are
  better able to understand stories that they hear
  and that they read themselves.
• Second, phonological awareness, or the ability to
  separate the sounds of the speech stream, is
  essential for early decoding of print.

Moreover, strong language abilities help children
to communicate more effectively with peers and
teachers.
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Physical/Motor Factors
Enhancing school readiness

• Basic health is obviously a foundational
  attribute for school success, but more specific
  motor skills are also important, such as

• being able to grasp a pencil properly or
• having enough strength and dexterity in the
  wrists and hands to use scissors.

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Enhancing capacity

• Before proceeding, I want to make an obvious but
  very important point, again pushing my prevention
  barrow.
• Todays children are tomorrows parents
• Studies of intergenerational relations support
  the old adage of you reap what you sow

(Belsky et al, Child Development, 2005)
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The strategy - behavioural health clinics in
schools
The time is right because

• Public awareness of prevention and effective
  treatments is rising.
• Alongside families, schools are the most
  important social institutions for young people.
• The strategies suggested would link the education
  and health care systems by providing a stepped
  pathway from prevention to care.

This proposal will improve the health and
life-skills of young people by building the
capacity of families, schools and the health care
system to respond to identified needs.
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Prevention

• A national school curriculum for personal
  development and health would provide an ideal
  platform for universal prevention strategies.
• Many of the life-skills needed by children can be
  taught. Computer aided teaching of skills for
  coping with life stresses is practical and
  programmes are being developed.
• These programmes are acceptable to teachers and
  students alike. This strategy builds upon
  existing New Zealand Government initiatives in
  both health and education.
• Apart from the development and implementation
  costs, the running costs of these programmes will
  be revenue neutral.

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Early intervention

• Teachers are the front line for the early
  detection and response to vulnerable young
  people.
• School psychologists should carry the main
  treatment load of mild and moderate cases, but
  are in short supply.
• It is recommended that a new cohort of
  psychologists be recruited and specially trained
  to treat the specific behavioural health needs of
  todays youth.

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Stepped care

• It would be difficult to recruit new school
  psychologists if they were expected to be solely
  responsible for the care of young people with
  more complex problems.
• Any system that cant refer complex cases will
  ultimately become gridlocked. Therefore, expert
  support for school psychologists is essential to
  enable them to refer appropriately.
• It is proposed that the additional school
  psychologists being recruited and specially
  trained for each school region in NZ be
  supervised by additional trained clinicians in
  each region.
• These people would, in addition to offering
  clinical support, be a guide to appropriate child
  and adolescent health services, whether
  paediatric or psychiatric.

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Upskilling existing specialists

• Communication and referral paths need to work
  smoothly and efficiently in both directions.
• Paediatricians already see and treat many
  disturbed young people, but few have had
  sufficient training for the role.
• They too need skills, tools and professional
  support appropriate for their new clinical role,
  analogous to the increased role for general
  practitioners in adult mental health.
• A number of PC and web based strategies show
  promise in expanding the reach and capacity of
  existing clinicians.
• Many current mental health service staff will
  also need additional training in new and
  effective non-drug therapies.

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Organisational framework

• The school regions in NZ represent the basic
  units of this system.
• Programme fidelity is critical to effectiveness.
• A steering committee should be formed to oversee
  the programme. It should include the developers
  of the proven prevention and early intervention
  programmes and experts from education, mental
  health and paediatrics.

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Health and personal development lessons via the
web
www.climateschools.tv
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Fidelity

• School-based health and personal development
  programmes are known to suffer from a lack of
  fidelity in implementation.
• Teachers often lack support or skills, and it is
  not uncommon for teachers to modify programmes
  based on their own values.
• In contrast, the web-based format for CLIMATE
  Schools ensures absolute fidelity with the
  evidence base. The Climate courses are augmented
  by resources for teachers.

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Scalability

• Another barrier to effective school-based
  interventions, and indeed many other
  interventions, is scalability.
• The history of both the mental health and the
  alcohol and other drug sectors is littered with
  innovative programmes that had been shown to be
  effective but were resource intensive and failed
  to obtain ongoing funding.
• Thanks to delivery via the web, Climate is
  infinitely scalable.

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Cost

• Climate can be operated on a not for profit
  basis, but should aim to recoup costs to maintain
  the service.
• In Australia the first 150 coupons are free to a
  school. After that the cost will be 1 per
  student per course.
• States and Territories may enter into individual
  contracts.

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Teacher support

• The Teachers Club is the administration centre
  of the programme.
• Each teacher who orders coupons is able to access
  the Club using their email address and a
  password.
• In the club they find tabs that lead to material
  on how to use Climate, ordering coupons,
  monitoring the progress of their students, the
  full details of each course, lesson support and
  professional development material.
• Help and contact tabs are included.
• There is a discussion forum.

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Evidence for effectiveness
RCT for alcohol intervention (n1466 year 8
students from 16 schools in NSW and ACT)
?

• RCT evidence for stress management (n464 year 8
  students in 6 schools in NSW)

?
RCT comparing computer-based v clinic-based
treatment for social phobia (n100) (The median
age of onset of social phobia is 13)
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The latter are the largest effect sizes ever
demonstrated from internet therapy.
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Addressing the gaps in our knowledge
There is still a lot we dont know. For
example, the 2007 UNICEF report on Child
Well-being.
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And finally

• We cant do all things
• We need to focus on a limited number of
  achievable objectives ...
• Best bets for the biggest bang for our buck.
• Prevention offers a whole host of social, health
  and economic benefits for NZers.

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Acknowledgements

• This on-going research would not have been
  possible without the co-operation and commitment
  of the Study members, their families and friends
  over a long period of time.
• Core funding for the Dunedin Multidisciplinary
  Health and Development Research Unit comes from
  the Health Research Council of New Zealand.

For copies of research articles referred to in
this presentation or other information on the
Study, contact Michelle McCann ? 03 479-8507
? email dmhdru_at_otago.ac.nz http/www.ota
go.ac.nz/dunedin study