Prevention 311than preventing one or more disorders. We may also aim to prevent
symptoms or problems that would never quite have been severe enough
to be a disorder; or prevent distress; or prevent the development of poor
psychosocial functioning. Each of these additional goals can be pursued
with or without the others.
Prevention programmes may be:
1 Universal, covering the whole population. Potential advantages include
the opportunity to make the intervention generally acceptable and part
of the usual culture, so avoiding stigma; it may be easier to deliver
interventions universally too, as in putting fluoride in the water or
teaching all schoolchildren about the risks of taking drugs. Disadvan-
tages are the cost and resources required to implement universal cover,
especially if the intervention has no effect on most of the population. In
the child mental health domain, a potential example of a universal ap-
proach would be a series of television programmes influencing parents
to spend more time reading with their children and interacting with
them warmly while setting firm limits; there is good evidence that this
style of parenting improves attainment and reduces conduct problems,
especially in less advantaged populations.
2 Targeted/Selective, covering that part of the population at elevated risk
of developing a condition. Potential advantages include efficient use of
resources, thus avoiding unnecessary expense directed to individuals
who do not need it. Disadvantages include the need to have a screening
procedure that is acceptable, sensitive and specific, so that it picks
up those likely to have developed the condition, but not those who
wouldn’t have. Also, the screening procedure and the intervention may
be perceived as stigmatising, which may hinder uptake. For example, a
parent may not appreciate being invited to a group run by the social
services department for those believed to be at risk of abusing their
children. Another disadvantage is that although the targeted population
may be at considerably higher risk, most cases will occur in the rest of
the population. Thus, in the UK in the poorest tenth of the population,
the prevalence of conduct disorder is around 18%, compared with
around 5% in the rest of the population. Implementing a prevention
programme that was totally effective in eradicating conduct disorder in
those at risk because of poverty would still miss nearly three-quarters of
cases.
3 Indicated, covering those children who already show early signs of the
condition. An advantage of this approach is that it is most effective in
terms of only being used where necessary. Disadvantages include the
fact that considerable damage may already have occurred by the time
intervention is given, making the intervention more complex, costly,
and less effective than earlier prevention would have been. However,
intervening at this stage is still likely to be easier than when the full-
blown condition and its consequences for school work, friendships and
family relationships have been long established.