“If only” is a phrase we hear too often in mental health. If only we knew what was going on. If only they knew they weren’t alone. If only we had recognized the signs. If only we had access to treatment. If only. Unfortunately, the conversation tends to be short and after tragedy has already struck – suicides, homelessness, unemployment, and incarceration.
Fortunately, we know how to act early. Studies around the country prove over and over again that we are able to prevent or mitigate the effects of mental illness and allow individuals to live fulfilling, productive lives in the community. From the influence of genetics and prenatal health all the way into early adulthood, we are learning more about the critical points in brain development and life experiences that increase the risk for or provide protection against the development of mental health disorders.
Studies show that half of those who will develop mental health disorders show symptoms by age 14.[i],[ii] We know that the time between prenatal development and early adulthood is crucial for the brain. Despite this knowledge, we continue to fail our children by ignoring problems until they reach crisis levels. Instead of investing in prevention and early intervention programs and providing access to appropriate services, we have unconscionable rates of suicide, school drop-out, homelessness, and involvement in the juvenile justice system.[iii],[iv],[v],[vi] While we can work to provide mental health services and supports and to promote recovery for individuals in need, the overwhelming number of those struggling is a reminder of how often we wait too long to take action.
The information below presents a timeline of important factors we know are harmful to mental health throughout the early lifespan, and highlights several programs and policies that address risk factors and increase protective factors in order to promote the prevention and early intervention of mental illness.
Harmful or Helpful
Risks and protective factors are often used as a framework for addressing issues that impact prevention and early intervention of mental illness. Risk factors are harmful and impede recovery, while protective factors are helpful and support recovery. We have chosen to address harmful or helpful factors in four categories. While there is some overlap among the categories and no exact formula for how much a specific factor will affect an individual, these four categories provide a good framework for exploring the different ways we can support people in reaching their recovery goals. The categories are:
Does my brain and body have the ability to do the things I need? Traumatic brain injuries, chronic illnesses, and mental health disorders are common examples of health issues that impact our body and brain’s ability to do the things we would like. Health related issues that influence mental health also include toxic exposure, nutrition, and sleep, among others. Harmful or helpful factors that fall into this category are directly related to the physical body and brain’s ability to perform functions needed for people to live fulfilling lives.
- Safety or Security
Are there environmental or interpersonal factors that affect my ability to attend to or pay attention to the things I need? Trauma like abuse, neglect, experiencing sexual or physical violence, or exposure to violence interferes with our ability to pay attention to what we need. After traumatic experiences, many survivors respond with hypervigilance – a heightened state of fear and attention to one’s surroundings. In this way, many children who experience trauma become like child soldiers, paying close attention to any factor that might bring imminent harm. This change in attention makes it difficult for children when they try to focus on or respond to daily demands such as school or other everyday activities. Harmful or helpful factors in this category refer to external influences that impact how a person can lend appropriate and required attention to the things they need and want to do.
Do I have the tangibles or services available to meet my needs? This includes access to resources like adequate housing, nutritious food, finances, and education, as well as mental health services, like school based supports and mental health treatment. As Abraham Maslow understood in his Hierarchy of Needs, physiological needs like air, water, food, and shelter are the most basic requirements for an individual to function and thrive. When youth experience the early signs of mental illness (typically around puberty), having access to needed mental health resources like therapy, peer services, supported education, case management, integrated school and community care, and sometimes medication is crucial to prevent mental illness from getting worse. Harmful or helpful factors in this category refer to goods or services that support an individual’s physical and mental health and overall well-being.
Do I have interpersonal supports that help me meet my needs? This includes healthy and appropriate relationships with others, including caregivers, family, friends, or classmates. This also includes the extent to which the individual feels like a valued member of his or her community. While relationships can be a resource and contribute to whether we feel safe or insecure, they are given a separate category because of the special role healthy or unhealthy relationships can have for individuals. The negative effects of isolation are an all too common experience for individuals with mental illness. Programs and policies that address isolation or family and peer support deserve extra attention. Harmful or helpful factors in this category refer to the support a person needs and receives from those around him or her that impact health and well-being.
In addition to the four categories of harmful (risk) or helpful (protective) factors, we divided early lifespan into three distinct periods where specific social, emotional, and biological changes occur: the prenatal period to early childhood, early childhood to puberty, and puberty to early adulthood. These periods are critical times where we can take action to support children and young adults before they reach a crisis or when recovery becomes more difficult. For each stage, we provide research on important risk or protective factors and offer several policy and program options that have been shown to remove harmful factors or increase helpful factors. The hope is that support for these policy changes and implementation of prevention and intervention programs will reduce the number of families who will reflect on “if only” as well as decrease the over reliance on hindsight and reactionary practices that are used now to address mental illness.
Genetics and Brain Development
While many of the helpful and harmful factors discussed below address environmental factors, it is important to acknowledge the influence of genetics and brain development. Like many physical health problems, genes and brain development play a role in mental illness, and an individual has an increased likelihood for developing a specific disorder if others in his or her family have been diagnosed with that disorder.[vii] However, having a genetic predisposition to mental illness does not necessarily mean an individual will develop a mental illness. It does imply that there is an increased risk, which, when combined with other harmful factors, increases the possibility that someone will suffer with mental health problems. To further complicate, sometimes random mutation in brain development occurs such that even people born into safe and supportive environments, with access to needed resources, can continue to struggle with mental health problems.
Luckily, we know that genes and physical characteristics of the brain do not operate outside of influence from the environment. While we cannot yet change the genetic code someone is born with, by influencing the environment they live in we can have a positive influence on how a brain works and continues to grow (called neuroplasticity). This is not unlike how physical or occupational therapy supports a person following any physical injury.
There are critical periods during brain development where the brain goes through rapid growth and change. At birth, an infant will have almost all the neurons (nerve cells) it will ever have in its lifetime. However, within the first few years of life, the brain will develop twice the amount of synapses (structures that allows a neuron to transmit chemical and electrical signals to another neuron) as it will in adulthood.[viii] This process, called blooming, makes infancy a sensitive time for learning and engaging with outside information. Synapses that are engaged and used repeatedly become stronger. Blooming is followed by pruning – the elimination of unnecessary connections between neurons and strengthening of important connections. The pruning process has been especially tied to important brain development and mental health issues in adolescent years.[ix],[x],[xi] The timing of these changes (from infancy through puberty) provide additional evidence for why focusing on mental health problems among youth is critical, and why waiting until someone reaches adulthood is harmful. If we truly want to address mental illness, we must address all of the factors we know play a role in its development and we must address these factors early.
Prevention and Early Intervention in Mental Health Links
- Prenatal Period to Early Childhood
- Early Childhood to Puberty
- Puberty to Early Adulthood
- Consequences of Failing Our Children
- Prevention and Early Intervention Policy
Additional Prevention Analysis and Fact Sheets
The analysis below and accompanying fact sheets highlight critical information that can be used as a background for stakeholders interested in understanding and implementing preventive policies and practices in their communities.
- Paper - Primary Prevention in Behavioral Health (.pdf)
- Executive Summary - Primary Prevention in Behavioral Health
- Fact Sheet - Prevention and Mental Health
- Fact Sheet - Costs and Benefits
- Fact Sheet - Promotion and Prevention
- Fact Sheet - Trauma
Mental Health America hosted a webinar entitled "Flourishing: Positive Mental Health is Good Public Health" on April 13, 2011. Corey L.M. Keyes, PhD, Professor of Sociology at Emory University presented. You can download the powerpoint here.
William R. Beardslee, MD, from the Department of Psychiatry of Children's Hospital Boston and Harvard Medical School, joined MHA in presenting a webinar entitled "Prevention of Mental Health Conditions and Depression in Parenting: Implications of Two Recent IOM Reports." The materials are available for download here.
[i] Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27.
[ii] Paus, T., Keshavan, M., & Giedd, J. N. (2008). Why do many psychiatric disorders emerge during adolescence?. Nature Reviews Neuroscience, 9(12), 947-957.
[iii] Suicide Prevention. (2015, March 10). Retrieved from http://www.cdc.gov/violenceprevention/pub/youth_suicide.html
[iv] 30th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, 2008. (2011, December 1). Retrieved from https://www2.ed.gov/about/reports/annual/osep/2008/parts-b-c/30th-idea-arc.pdf
[v] The Characteristics and Needs of Families Experiencing Homelessness. (2011, December 1). Retrieved from http://www.familyhomelessness.org/media/306.pdf
[vi] Better Solutions for Youth with Mental Health Needs in the Juvenile Justice System. (2014). Retrieved from http://cfc.ncmhjj.com/wp-content/uploads/2014/01/Whitepaper-Mental-Health-FINAL.pdf
[vii] Cross-Disorder Group of the Psychiatric Genomics Consortium. Genetic relationship between five psychiatric disorders estimated from genome-wide SNPs. Nature Genetics, August 11, 2013.
[viii] Baby's Brain Begins Now: Conception to Age 3. Retrieved from http://www.urbanchildinstitute.org/why-0-3/baby-and-brain
[ix] Casey, B. J., Jones, R. M., & Hare, T. A. (2008). The adolescent brain. Annals of the New York Academy of Sciences, 1124(1), 111-126.
[x] Paus, T., Keshavan, M., & Giedd, J. N. (2008). Why do many psychiatric disorders emerge during adolescence?. Nature Reviews Neuroscience, 9(12), 947-957.