Prevention for Children’s Mental Health: Key Strategies

Mental health challenges are recognized as the foremost cause of disease worldwide, with a significant majority arising before individuals reach the age of 14. The increase in mental health issues among children and young people (CYP) in recent years is concerning, largely due to factors such as the COVID-19 pandemic and the resulting widespread social isolation. These trends present a major public health challenge that demands urgent attention (Racine et al., 2021; Wykes et al., 2023).

Furthermore, the alarming rates of suicide within the CYP demographic highlight the pressing need for effective interventions. A recent review by Edwards et al. (2024), which I discussed earlier this year, indicates a growing demand for crisis services tailored to this vulnerable population, underscoring the necessity for impactful preventive measures. Although there is an increasing array of evidence-based treatments available for CYP (Kieling et al., 2011; Klasen & Crombag 2013), accessibility continues to pose a significant challenge, with many CYP experiencing prolonged waiting periods for necessary treatment (Department of Health, 2015; Radez et al., 2021). Implementing effective prevention strategies is essential, not only to provide immediate psychological and social benefits but also to significantly reduce the likelihood of mental health disorders in adulthood (Wykes et al., 2023).

This blog post will delve into a “review of reviews” conducted by McGovern et al. (2024), which sought to map the landscape of preventive interventions aimed at mitigating mental health issues in CYP. The review highlights successful strategies that can be utilized to inform practice and enhance outcomes.

Systematic Review Methodology for Evaluating Preventive Interventions

This comprehensive review followed the PRISMA guidelines and was pre-registered on PROSPERO to ensure methodological rigor. A total of six databases were thoroughly searched, in addition to scrutinizing reference lists from relevant studies and reaching out to experts in the field to uncover unpublished work. To qualify for inclusion, studies had to be systematic reviews of randomized controlled trials (RCTs), quasi-experimental studies, or evaluations of secondary preventive interventions specifically for CYP (or their parents) aged between 3 to 17 years. No constraints related to language or publication date were imposed.

Two independent reviewers conducted a rigorous screening and evaluation of the studies, with any discrepancies resolved through discussion or consultation with a third researcher. Data extraction was performed using a piloted form, and the synthesis was categorized by intervention type, with a quality assessment executed using the AMSTAR 2 framework. While studies were not excluded based on quality ratings, these ratings did inform the overall confidence in the evidence synthesis. The majority of studies received a critical low rating (n = 23), with 12 rated as high, five as moderate, and nine as low.

Key Findings on the Effectiveness of Mental Health Interventions

Upon completing the screening process, 54 papers that reported on 49 unique reviews were successfully included. These reviews encompassed a wide range of studies, with each review containing between 2 to 249 unique studies (M = 34), of which approximately 70% were RCTs.

The reviews assessed interventions that were classified as selective (n = 22), indicated (n = 15), or a combination of both (n = 12):

• Selective interventions target the prevention of mental illness among CYP who are at an elevated risk due to various biological, psychological, or social factors.
• Indicated interventions are designed for CYP already displaying pre-clinical symptoms, as noted by Cho & Shin (2013).

Selective interventions specifically aimed at CYP experiencing adversity, minority groups, and young mothers, while indicated interventions focused on addressing subclinical internalizing and externalizing problems, as well as self-harm behaviors.

Insights on the Effectiveness of Selective Interventions

• Reviews with high to moderate confidence demonstrated effectiveness for CYP undergoing adversity, especially those with parents struggling with mental health issues.
• Interventions such as cognitive behavioral therapy (CBT), psychoeducation, and resilience-building exercises yielded positive outcomes, including reductions in depressive symptoms and the prevalence of internalizing disorders.
• Creative arts therapies and family counseling also indicated promising results.
• Conversely, one review indicated no significant improvement in Post-Traumatic Stress Disorder (PTSD), depression, or anxiety for CYP affected by humanitarian crises.
• Moderate evidence emerged from a review supporting suicide prevention strategies among indigenous adolescents, although the effects on ideation or attempts were not thoroughly evaluated.
• Reviews rated as low to critically low presented mixed results.

Evaluating Indicated Interventions: Effectiveness and Outcomes

• High-confidence reviews suggested success in alleviating externalizing problems through school-based social skills and resilience training, with observed small effects post-intervention and at 12-month follow-ups.
• CBT proved effective in addressing subclinical internalizing issues, significantly reducing depression shortly after intervention and at subsequent short-term follow-ups (e.g., 6 months), along with anxiety reductions during these follow-ups.
• One review noted that dialectical behavior therapy (DBT) was effective in decreasing instances of self-harm.
• Low- and critically-low confidence reviews provided mixed findings across various indicated interventions, including parenting programs and psychosocial strategies, with some showing effectiveness in lessening depression and anxiety.

Ultimately, reviews with high or moderate confidence regarding combined secondary interventions showed overall effectiveness in alleviating mental health issues such as conduct disorders, depression, anxiety, and PTSD. However, reviews rated as low or critically low often reported minimal effects on both externalizing and internalizing issues, with certain exceptions indicating larger decreases in anxiety.

Key Takeaways from the Review Findings

This systematic review of reviews revealed a wealth of evidence supporting both selective and indicated interventions directed at at-risk CYP across diverse populations and settings. Selective interventions, particularly those targeting CYP who have faced adversity, displayed the strongest evidence of efficacy. Effective methodologies included CBT, psychoeducation, and family therapy, emphasizing strategies for risk mitigation and resilience enhancement. However, the evidence surrounding interventions specific to PTSD and self-harm remains limited.

The implications of these findings underscore the critical need for preventive strategies tailored for CYP facing adversity, suggesting that integrating resilience-building practices and risk reduction strategies could significantly enhance mental health outcomes for those vulnerable to future challenges.

Strengths and Limitations of the Review

This review utilizes a comprehensive international literature approach to map a wide array of preventive interventions, thereby allowing for a more thorough synthesis of findings. This methodology enhances the potential to identify best practices across various contexts, which can subsequently inform policy and practice recommendations grounded in solid evidence. However, despite the extensive scope of this undertaking, the inclusion of reviews focusing on interventions conducted in low-and-middle-income countries (LMICs) was limited. Given that approximately 90% of the world’s CYP reside in LMICs and are at a heightened risk of mental health challenges due to social disadvantages, poverty, and adversity (Riberio et al., 2023), this gap represents a critical area for further exploration. The scarcity of evidence in this domain suggests that there is still much to learn.

Robust methods were employed to ensure the dependability of the results; however, since the reviews generally amalgamated estimates from various preventive interventions, identifying which interventions were the most effective posed a challenge for this review of reviews. As a result, while this analysis provides an accessible overview of existing evidence, addressing multiple sub-populations of CYP across diverse contexts, the review was unable to conduct a meta-analysis to pool the effects of different interventions, which limits its capacity to draw definitive conclusions.

It is essential to recognize that comparing different studies can be misleading. This review of reviews includes findings from studies encompassing a broad age spectrum, variations in intervention intensity and duration, and differences in comparative conditions. Merging these outcomes could result in misleading interpretations and inaccurate generalizations, potentially undermining the effective implementation of these interventions. Furthermore, compiling a review of reviews has led to the inclusion of some individual studies in multiple reviews, which could lead to double counting of evidence, skewing overall conclusions, and potentially overstating the effectiveness of certain strategies.

Practical Implications of the Review Findings

The insights gleaned from this review indicate that successful preventive interventions frequently integrate multiple components that focus on risk mitigation and resilience enhancement across various domains, including behavioral, interpersonal, cognitive, and emotional facets. Adopting a holistic perspective on mental health for CYP is critical, as all these domains are interlinked, each impacting the others. For instance, improving emotional regulation (emotional) can decrease impulsive behaviors (behavioral), which subsequently strengthens relationships with peers and family (interpersonal). Similarly, cultivating positive thinking and problem-solving abilities (cognitive) can assist CYP in managing stress and navigating challenges more effectively, thereby lowering emotional distress risks. These interdependencies imply that addressing a single domain in isolation may be insufficient for long-term mental health improvements, while a comprehensive approach that targets all domains lays a stronger foundation for mental well-being.

Identifying promising selective interventions may reduce the necessity for individual risk assessments, as these interventions are crafted to benefit specific groups of CYP sharing common risk factors, rather than requiring a detailed evaluation of each individual’s risks. This strategy enables a more efficient and effective allocation of resources, allowing interventions to be implemented at a population level to assist those at risk without needing to assess each person’s unique circumstances. Conversely, the identification of effective indicated interventions facilitates targeted support for CYP displaying early signs of mental health challenges or those at high risk of developing such issues. The advantage of indicated interventions lies in their proactive nature; by addressing challenges at an early stage, they can prevent the escalation of mental health issues and enhance overall functioning and well-being. This focused approach also improves resource efficiency, concentrating efforts on those most likely to benefit from intervention.

During my experience working in Tier 4 Inpatient Child and Adolescent Mental Health Services (CAMHS), I encountered CYP in crisis who struggled to manage their mental health within the community. I often heard about the obstacles they and their families faced in obtaining appropriate support, frequently noticing behavioral changes and vulnerabilities long before hospitalization was necessary. The restrictive nature of inpatient care and the separation from their social environment reinforced the critical need for preventive interventions. This review highlights encouraging advancements in this domain, offering hope that CYP and their families may soon have access to community-based support to maintain their mental well-being and avert future crises.

Strategic Recommendations for Implementation

• Prioritize early intervention strategies for CYP who have faced adversity to prevent the onset of mental health issues.
• Provide comprehensive training for practitioners and stakeholders to ensure they possess the necessary skills to implement interventions effectively.
• Build local capacity to foster ownership and commitment to mental health initiatives.
• Integrate interventions within existing mental health services or educational frameworks to ensure ongoing support and alleviate the burden of establishing new systems. This integration also enhances continuity of care for CYP.
• Design interventions to be adaptable to various settings, cultures, and populations, ensuring relevance and effectiveness across diverse communities. This flexibility promotes broader adoption and integration into existing systems.
• Secure sustainable funding sources to ensure the long-term viability of interventions.

Disclosure of Conflicts of Interest

No conflicts of interest to declare.

Essential References for Further Reading

Primary Paper Reference

McGovern, R., Balogun-Katung, A., Artis, B., Bareham, B., Spencer, L., Alderson, H., … & Kaner, E. (2024). The effectiveness of preventative interventions to reduce mental health problems in at-risk children and young people: a systematic review of reviews. Journal of Prevention, 1-34.

Additional References for Context

Cumber, B. (2024). Are crisis responses for children and young people effective? The Mental Elf.

Cho, S. M., & Shin, Y. M. (2013). The promotion of mental health and the prevention of mental health problems in child and adolescent. Korean Journal of Pediatrics, 56(11), 459–464.

Edwards, D., Carrier, J., Csontos, J., Evans, N., Elliott, M., Gillen, E., … & Williams, L. (2024). Crisis responses for