Child and Adolescent Psychiatry

314 Chapter 37

of 7,000 18-year-olds. A risky lifestyle was defined on a scale of 0–8 risks,
involving being in the worst 10–20% of the population for (i) drinking
alcohol; (ii) drug use; (iii) being known to social services; (iv) having
special education needs; (v) truanting; (vi) having conduct problems at
school; and (vii) running away from home. The presence of protective
factors was counted up to maximum of 5 from (i) good physical health;
(ii) higher IQ; (iii) emotional control; (iv) social skills and maturity; and
(v) energy levels. In the absence of risk indices, having protective factors
in childhood made little difference to crime rates. But in their presence,
the protective factors conferred very substantial benefits, greatly reducing
the crime rates. The implication is that to maximise the effectiveness of
prevention programmes in child mental health, these programmes should
promote skills and resilience as well as targeting the symptoms of disorder.

Box 37.2Impact of resilience factors on crime rate, stratified by

number of risks (based on data from Stattin and Magnusson, 1996)

percent of youths arrested

25

20

15

10

5

0

None 1 or 2

Resilience factors

Many risks (4+)

Some risks (2 or 3)

No risks

3 +

An exciting prospect for preventive programmes in childhood is their po-
tential for large effects, if they prevent disorders and improve functioning
over the lifespan. Yet so far, few have been widely adopted, despite accu-
mulating evidence of effectiveness. This is perhaps surprising where med-
ical preventions of much more dubious benefit are endorsed by the state,
for example, in the UK medication that shortens the course of influenza
by only one or two days. One reason for the lack of implementation of
child psychiatric preventions is the paucity, at present, of good evidence
of the burden of disorders. There are few ‘cost of illness’ studies for most
child psychiatric disorders, and no generally accepted Quality of Life (QoL)
measures that allow comparison with the impact of physical disorders.
Medical illness QoL measures cover dimensions such as pain, mobility,
ability to communicate, and ability to care for oneself. These do not