essay on the youth intervention for a new dawn

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At A New Dawn’s community center, Bedouin youth, who have dropped out of school, take part in diverse programming geared towards their development and empowerment.

Programs include: employment training courses, leadership development programs, social business ventures, hosting groups from abroad and much, much more.

A New Dawn’s youth workers provide personal support and guidance while contending with rising trends in school dropout rates, violence and unemployment to help shape the next generation of Bedouin adults. Once the youth turn 18 they graduate the Youth Empowerment program and begin our ‘Next Steps’ employment placement program. 

• Address: Alsalam St. Rahat, Israel
• POB 150, Neighborhood 17, 112 85357 Rahat, Israel

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Introduction

• Published: November 2008
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Prevention rather than cure is the obvious, common-sense approach to dealing with any problem, and it is unsurprising that criminal justice policy has been driven by such an ideal. Shortly after entering government in 1997, New Labour embarked on what was seen by many commentators as a more holistic model of crime prevention than its predecessor Conservative government had utilised, with the establishment of Crime and Disorder Reduction Partnerships. This book examines government policy in the United Kingdom in relation to early intervention programmes that aim to support families and to prevent youth crime. It raises some important questions about prevention strategies, such as whether early intervention is symptomatic of a creeping criminalisation of social policy whereby a coercive approach is used to force so-called problem families and their children to engage with services; how local people themselves are engaged in crucial decisions about how to tackle crime and social problems; and how those most detached from the mainstream can be motivated to take advantage of support provided.

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• Open access
• Published: 24 March 2020

Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care?

• Marco Colizzi 1 , 2 ,
• Antonio Lasalvia 1 &
• Mirella Ruggeri 1  

International Journal of Mental Health Systems volume  14 , Article number:  23 ( 2020 ) Cite this article

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Similar to other health care sectors, mental health has moved towards the secondary prevention, with the effort to detect and treat mental disorders as early as possible. However, converging evidence sheds new light on the potential of primary preventive and promotion strategies for mental health of young people. We aimed to reappraise such evidence.

We reviewed the current state of knowledge on delivering promotion and preventive interventions addressing youth mental health.

Half of all mental disorders start by 14 years and are usually preceded by non-specific psychosocial disturbances potentially evolving in any major mental disorder and accounting for 45% of the global burden of disease across the 0–25 age span. While some action has been taken to promote the implementation of services dedicated to young people, mental health needs during this critical period are still largely unmet. This urges redesigning preventive strategies in a youth-focused multidisciplinary and trans-diagnostic framework which might early modify possible psychopathological trajectories.

Conclusions

Evidence suggests that it would be unrealistic to consider promotion and prevention in mental health responsibility of mental health professionals alone. Integrated and multidisciplinary services are needed to increase the range of possible interventions and limit the risk of poor long-term outcome, with also potential benefits in terms of healthcare system costs. However, mental health professionals have the scientific, ethical, and moral responsibility to indicate the direction to all social, political, and other health care bodies involved in the process of meeting mental health needs during youth years.

Promotion, prevention and early intervention strategies may produce the greatest impact on people’s health and well-being [ 1 ]. Screening strategies and early detection interventions may allow for more effective healthcare pathways, by taking action long before health problems worsen or by preventing their onset [ 2 ]. They also allow for a more personalized care in terms of tailoring health interventions to the specific sociodemographic and health-related risk factors as well as activating interventions specific to illness stage [ 3 ]. In this regard, the application of clinical staging models has been suggested to improve health benefits, by addressing the needs of people presenting at different stages along the continuum between health and disease [ 4 ]. Despite challenging, reformulating health services in this perspective may increase prevention and early intervention effectiveness, disease control and overall care, positively impacting on the health and well-being outcomes of a broader population [ 5 ]. Not to be overlooked, it may potentially reduce disease burden and healthcare system costs [ 6 ].

The need for implementing prevention and early intervention in youth mental health

Prevention and early intervention are recognized key elements for minimizing the impact of any potentially serious health condition. However, while representing a field of remarkable achievement, that of early intervention in youth health is a target not completely accomplished yet [ 7 ]. This is particularly true for youth mental health. In fact, mental healthcare has been traditionally oriented to provide health benefits to adult populations during crisis events and major emergencies [ 8 ]. In this framework, mental health presentations to emergency settings in pediatric populations are somewhat frequent events [ 9 ]. Deinstitutionalization policies have only partially addressed this issue, also in light of the large variability worldwide in the implementation of community mental health services [ 10 ], especially for children and young adults [ 11 ].

Theoretical considerations about the opportunity to intervene in this specific age window in terms of mental health follow a number of evidence-based considerations. First , mental health is a key component of the person’s ability to function well in their personal and social life as well as adopt strategies to cope with life events [ 12 ]. In this regard, early childhood years are highly important, in light of the greater sensitivity and vulnerability of early brain development, which may have long-lasting effects on academic, social, emotional, and behavioral achievements in adulthood [ 13 ]. Second , most mental disorders have their peak of incidence during the transition from childhood to young adulthood, with up to 1 in 5 people experiencing clinically relevant mental health problems before the age of 25, 50% of whom being already symptomatic by the age of 14 [ 14 ]. Among people younger than 25 years old, mental health problems, especially anxiety and mood disorders, are the main cause of disability-adjusted life-years (DALYs), accounting for 45% of the global burden of disease, with problematic substance use including alcohol and illicit drugs being the main risk factor for incident DALY (9%) [ 15 ]. Third , most mental health services, as traditionally developed, have proven to be ineffective to provide healthcare during this critical period [ 16 ], with a modest use of mental health services despite the high prevalence of mental health problems among young individuals [ 17 ]. Also, following symptom onset, people aged 0–25 experience the greatest delay to initial treatment [ 18 ]. This is mainly due to two reasons. On one hand, young individuals, especially male, socioeconomically disadvantaged, and of ethnic minority, are less likely to establish initial contact with mental health services and stigma represents a major barrier in this regards [ 19 ]. When they do, they show high rates of disengagement [ 20 ]. On the other, significant delays in receiving care are also attributable to the reduced ability of services to rapidly deliver specialist mental healthcare for youth in need after a first primary care consultation [ 21 ]. When treatments are finally offered, the majority are not evidence-based [ 16 ].

Based on evidence summarized above, there is a pressing need to develop, or improve where present, youth mental healthcare models which can implement prevention and early intervention strategies. While progress has been made for psychotic disorders, also due to the successful application of an at-risk mental state concept [ 22 ], this is still largely unexplored in the context of common mental disorders, such as depression, anxiety, substance abuse, and eating disorders [ 23 ]. In order to meet the need for early intervention into childhood and young adulthood mental health difficulties, it is imperative to parallel redesign prevention and early intervention services for young populations, by promoting multidisciplinary collaborations between different specialized professionals in an enhanced and integrated service of extended primary care [ 5 ].

The aim of this narrative review is threefold: (i) to update on the current debate on the at-risk mental state concept and the possibility of widening the clinical area of intervention beyond psychotic disorders; (ii) to review the role of psychosocial difficulties early in life as potentially stable risk factors for poor mental health, and the extent to which they have been targets for early intervention; and (iii) to report on the progress made so far in implementing collaborative and integrated services for youth mental health within the healthcare system.

The current literature review is intended to bring together research evidence on early life risk factors detection, youth mental health service provision, and application of a clinical staging model by using a trans-diagnostic approach. In particular, the present work aims to emphasize the relationship between these early intervention components and offer new directions for clinical research into the full development of a youth-based model of mental healthcare focused on prevention.

Search strategy

A literature search was performed using electronic databases (MEDLINE, Web of Science, and Scopus), using a combination of search terms describing risk factors, clinical staging, and multidisciplinary prevention and early interventions in youth mental health. Special attention was given to available research of the past 25 years as a major transition in the clinical characterization of the prodromal phase of major psychiatric disorders in youth has occurred during the past 2 to 3 decades [ 21 ]. In addition, some research evidence gathered outside this search was reported, if considered appropriate by all authors.

Eligibility criteria

Studies were eligible for inclusion in this review if assessing preventing strategies in youth in a trans-diagnostic and multidisciplinary approach. Studies were excluded in they (i) did not assess the application of a clinical staging model for youth mental health in a trans-diagnostic framework; (ii) did not investigate youth mental health service provision in a multidisciplinary framework; (iii) primarily assessed risk factors and preventive strategies in older populations rather than youth.

Towards a trans-diagnostic clinical staging model to intercept a wider at-risk youth population

Over the nineteenth century, the so-called “prodromal state” (i.e. the period preceding the onset of severe mental disorders), was seen as a phase characterized by low-intensity or low-severity symptoms not sufficient to justify a categorical diagnosis, but whose ineluctable progression to full-blown disorder was only a matter of time. Towards the end of the last century, the formulation of the “at-risk mental state” concept [ 22 ] has represented a milestone in the development of a preventive approach to mental disorders, by overcoming the stagnant idea of inevitably ominous prognosis. This has dramatically loosened the deterministic approach to more severe mental disorders, such as schizophrenia, in favor of a more cautious approach to the potential future evolution of the condition in a psychosis-spectrum context where milder forms of the disorder and recovery are still possible. After a period of struggle to translate this paradigmatic advance in more effective mental healthcare practices, mostly because of the restrictive application of notions of “risk” and “transition” on the basis of positive psychotic symptom manifestation alone [ 24 ], we are finally facing a new turning point. Research evidence has increasingly recognized that, in addition to transition to psychosis, longer-term psychotic disorder, or persistent sub-threshold psychotic symptoms, progression to persistent mood, anxiety, personality and/or substance use disorders is also a very common outcome [ 25 , 26 ]. This adds to the independent evidence that during development risk factors may contribute to a range of psychopathologies, and early indicators of later risk are often dimensional [ 27 ]. For instance, childhood adversities seem to impact negatively on a number of disorders [ 28 ]. Thus, in order to better characterize pluripotent and trans-diagnostic developmental processes and bio-behavioral mechanisms that give rise to mental illness, cross-disciplinary approaches need to integrate, if not overcome, the traditional diagnostic approach.

In this regards, integrated youth mental health services for people who are still in the earlier stages of a mental disorder may benefit from a wider clinical staging model framework far beyond the limited ultra-high risk (UHR) paradigm for psychosis. In particular, a trans-diagnostic clinical high-risk mental state (CHARMS) paradigm may increase capacity to intercept a wider range of lower risk cases than those with attenuated psychotic symptoms only, including people with sub-threshold bipolar and borderline personality symptoms as well as mild-moderate depression [ 22 ] (Fig.  1 ).

A trans-diagnostic clinical staging model to intercept a wider clinical high-risk mental state population

Youth mental health: which targets for which interventions?

Neurodevelopmental changes occurring during youth make it a period of both vulnerability and opportunity for mental health. Research evidence indicates that a number of factors influence the person’s mental health from before birth until early adulthood, after which mental health can still be significantly modulated but to a lesser extent [ 29 ]. Meeting the child’s physical (i.e. healthy nutrition), psychological (i.e. stable and responsive attachment relationships), and social (i.e. supportive and safe environments) needs is key element to support optimal brain development, emotional regulation, and higher order cognitive function, with long-lasting health benefits [ 30 ]. Conversely, adversities during pregnancy and early childhood such as inadequate care, neglect, and trauma, have been shown to negatively impact on academic trajectories, psychosocial skills, physical resilience and the possibility of healthy aging [ 29 , 31 ]. Also, depending on their nature, whether risk or protective factors, such environmental determinants may differentially modulate gene expression and stress response, with enduring health effects [ 32 ]. For instance, evidence from gene-environment interaction studies suggests that children carrying specific genetic variants are at increased risk for behavioral problems in later life, but only when raised in dysfunctional families [ 33 ]. Similarly, regardless their severity, stressful life events produce the most ‘toxic’ effect on children’s stress system, raising the risk of subsequent development of stress-related mental difficulties, when experienced in the absence of a stable and supporting environment [ 34 ]. In this context, it appears particularly relevant the development of a secure attachment between the child and a protective primary caregiver, in order to facilitate adaptive emotional and behavioral responses to stressful events [ 35 ]. In its absence, neurodevelopment may be undermined, making that person more vulnerable to further environmental insults and subsequent development of both internalizing [ 36 ] and externalizing [ 37 ] behavioral problems, including anxiety, depression, substance misuse, maladaptive eating patterns, sexual risk behavior, and suicidality. The relation between attachment difficulties and youth psychological problems is most likely bidirectional, such that problematic behaviors during childhood and adolescence may also precipitate difficulties in the caregiver-child/adolescent attachment bond, or exacerbate preexisting dysfunctional patterns [ 38 ]. Research has shown that internalizing and externalizing disorders of childhood are associated with an increased likelihood to develop a psychiatric disorder later in adulthood [ 39 ]. Interestingly, stringent tests of homotypic (a disorder predicting itself overtime) and heterotypic (different disorders predicting one another over time) prediction patterns suggest an increasingly developmentally and diagnostically nuanced picture, including but not limited to: (i) cross-prediction between anxiety and depression from adolescence to adulthood; (ii) adolescent oppositional defiant disorder, anxiety and substance disorders entirely accounting for the homotypic prediction pattern of depression overtime; and (iii) internalizing and externalizing psychopathology predicting psychosis-like experiences and vice versa [ 40 ]. Overall, these findings highlight how single disorder-oriented trajectories offer limited prospects for preventive interventions. Instead, interventions addressing multiple co-occurring problems are more likely to impact positively on youth mental health, potentially interrupting the continuity between childhood internalizing and externalizing psychopathology that may also co-occur with psychosis-like experiences on one hand, and psychiatric disorders in adulthood on the other. A large survey conducted by the World Health Organization (WHO) among 51,945 adults in 21 countries reported that eradication of childhood adversities, especially those associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect), would lead to a 29.8% reduction of any mental disorder lifetime, and an even higher reduction when considering exclusively adolescence- (32.3%) and childhood-onset (38.2%) cases [ 28 ]. The possibility of preventing nearly one in two childhood-onset mental disorders is of crucial importance when considering that the experience of a mental disorder “kindles” a cascade of events which make recurrence later in life more likely [ 41 ]. Thus, promoting selective preventive strategies supporting children’s physiologic reactivity, cognitive control, and self-regulation through parenting- and classroom-based interventions, may represent a massive preventive action and ensure the earliest possible access to intervention with a view of limiting the continuity of mental health problems from childhood through to adolescence and adulthood.

A summary of risk factors and pluripotent pathological trajectory for mental disorders encompassing the youth prevention and early intervention window is provided in Fig.  2 .

Summary of risk factors and pluripotent pathological trajectory for mental disorders

Mental health prevention and early intervention in youth: where is the evidence?

Promotion of youth mental health.

Mental health promotion focuses on enhancing the strengths, capacity and resources of individuals and communities to enable them to increase control over their mental health and its determinants. Prevention, on the other hand, aims to reduce the incidence, prevalence and severity of targeted mental health conditions [ 42 ]. In order to fill the treatment gap for mental, neurological, and substance use disorders worldwide, evidence-based guidelines developed by the WHO recommend that population level health interventions had an overall promotion focus. This is in line with the well-established continuum of care between interventions promoting positive mental health, interventions striving to prevent the onset of mental health disorders (primary prevention), and interventions aiming at early identification, case detection, early treatment, and rehabilitation (secondary and tertiary prevention) [ 43 ].

Meta-analytic work strongly supports the effectiveness of youth prevention programs addressing child abuse [ 44 ], negative consequences of parents’ divorce on children [ 45 ], substance abuse [ 46 ], and school-related problematic behaviors [ 47 ] in reducing rates of psychosocial difficulties later in life [ 48 ]. In this regard, multimodal preventing programs combining preschool intervention and family support have been associated to the most enduring beneficial effects on a number of social outcomes, including significant better overall academic performances and lower delinquency and antisocial behavior rates [ 49 ]. However, it is worth mentioning that promotion practices suffer from different mental health policies and social and contextual determinants. For instance, some health and social domains such as education, housing, nutrition, and healthcare, have pervasive influence on low income settings, while lack of supportive environments and community networks may have more detrimental effects in urban areas with high population density or ethnic minorities [ 50 , 51 ]. Most likely, promotion programs require tailoring to the specific socio-cultural setting. Depending on its critical issues and what interventions are needed most, the implementation of effective programs goes through reorienting health services. Also, dialogue between health research, health professionals, health service institution, and governments is of paramount importance, especially to deliver integrated and multidisciplinary actions for the benefit of the entire community [ 50 ].

Primary prevention in youth mental health

Developmental model for primary prevention.

Primary prevention strategies may be universal, selective, or indicated, depending on whether they target the general population, a sub-group of the population, or specific individuals, respectively [ 42 ]. Rather than being separate, they should be seen as an integrated set of preventive interventions that continue throughout the neurodevelopmental stages of life as well as the intensification of risk [ 52 ].

Universal prevention (pre-clinical stage)

Mental health universal prevention aims at promoting normal neurodevelopment. Even though there is no consensus on which might be the pathophysiological mechanisms to be addressed during early development, promising findings suggest that developmental anomalies and behavioral deficits observed during childhood may be, at least partially, modifiable [ 53 ]. A number of effective pharmacological and psychosocial interventions for universal prevention have been identified, including: (i) perinatal phosphatidylcholine [ 54 ] and N -acetylcysteine [ 55 ] administration to support infants’ brain development and anti-inflammatory neuroprotection; (ii) lifetime omega-3 fatty acid [ 56 , 57 , 58 ], vitamin [ 57 , 58 , 59 ], sulforaphane [ 60 ], and prebiotic [ 61 ] supplementation to support good mental health by reducing neuroinflammation, oxidative stress, and microbiota dysbiosis; (iii) school-based behavioral interventions to minimize risk of bullying and peer rejection [ 62 , 63 ] as well as substance abuse [ 64 , 65 ]; (iv) exercise training to support brain plasticity [ 66 ], structure [ 67 ] and connectivity [ 68 ] as well as cognitive functioning [ 69 ].

Selective prevention (clinical stage 0)

Selective interventions aim at preventing the manifestation of psychiatric symptoms, thus altering the developmental pathway to full-threshold disorders in the premorbid state. Recipients of these interventions are individuals whose risk of developing a mental disorder is significantly higher than the rest of the population, while still being asymptomatic [ 42 ]. A number of risk factors have been identified, including parental mental illness [ 70 ], paternal age [ 71 ], maternal and obstetric complications of pregnancy [ 72 , 73 ], season of birth [ 74 ], ethnic minority [ 75 ], immigration status [ 76 ], urban environment [ 77 ], infections [ 78 ], childhood adversities [ 28 ], vitamin D deficiency and malnutrition [ 79 ], low premorbid intelligence quotient [ 80 ], traumatic brain injury [ 81 ], and heavy tobacco [ 82 ] and cannabis use [ 83 , 84 ].

It is worth reporting that most risk factors are shared across multiple mental disorders, suggesting the poor validity of boundaries between diagnostic categories, at least at this stage [ 85 ]. Also, while some risk factors are easily correctible (e.g. vitamin D deficiency) or technically preventable (e.g. cannabis use, infections), other require restructuring the role of the youth mental health professional as well employing a cadre of paraprofessionals to work more intensively with a large population of at-risk young individuals (e.g. childhood adversities), and for still others it is difficult to envisage programs ethically or practically sustainable (season of birth, urban environment) [ 86 ]. A few studies evaluated the effectiveness of prenatal and early infancy preventive programs for infants and children who may be socially disadvantaged or potentially at risk [ 87 , 88 ]. Results supported long-term positive effects of nursing home visits to expectant mothers and their families in difficult social circumstances [ 87 ] as well as school educational interventions and home teaching to support low-income families and their preschool children [ 88 ] in reducing child abuse, neglect, and criminal behavior as well as improving the use of welfare and family socioeconomic status [ 87 , 88 ].

To date, timing school-based mental health assistance, assertiveness training, and stress and anxiety management have the greatest chance to prevent maladaptive behavior and symptomatic manifestations [ 89 ]. Finally, while there is no clear research evidence favoring selective interventions in specific targeted populations, a promising strategy has been suggested to be the identification of those young individuals exposed to these risk factors who also have a family history of severe mental illness, in light of the per se higher genetic component for risk of mental disorders [ 90 ].

Indicated prevention (clinical stage 1)

Indicated interventions aim at the identification of those individuals at clinical high risk for the development of a mental disorder who are functionally impaired and no longer asymptomatic [ 42 ]. Psychosis studies have identified in the first 2 years following the manifestation of functional impairment a period of particular risk for transition to full-blown disorder [ 91 ], with about a third only in remission [ 92 ]. More recently, a shift towards a broader focus no longer confined to the psychosis risk identification has been suggested, in line with the increasingly clear evidence that pathways to mental disorders are pluripotent and trans-diagnostic [ 22 ]. This follows also the evidence that a so narrowed approach guarantees a limited detection, approximately 5%, even for those patients who will eventually develop a first episode of psychosis [ 93 ]. In this respect, complimentary evidence comes from a large meta-analysis that evaluated the impact of indicated preventive actions among 4470 at-risk students presenting with a range of problems including depression, anxiety, anger, general psychological distress, cognitive vulnerability, and interpersonal problems [ 94 ]. Intervention strategies included cognitive-behavioral, relaxation, social skills training, general behavior, social support, mindfulness, meditation, psychoeducational, acceptance and commitment therapy, interpersonal psychotherapy, resilience training, and forgiveness programs. Results suggested that indicated interventions have positive effects not only in reducing the presenting problem but also in improving other areas of psychosocial adjustment [ 94 ].

Indicated interventions are still preventive and aim at altering the trajectory of mental disorders. Research evidence suggests that the development of services for indicated prevention has met the objectives of strengthening service engagement, reducing the duration of untreated illness, and liaising with secondary prevention interventions [ 42 ]. In particular, reducing the duration of untreated illness has been robustly shown to impact positively on the outcome of first-episode psychosis and schizophrenia in many ways [ 95 ]. Increasing evidence suggests a similar effect for other psychiatric disorders including major depressive disorder, bipolar disorder, panic disorder, generalized anxiety disorder, and obsessive–compulsive disorder [ 96 ]. Importantly, as some pre-diagnostic symptoms and neurobiological correlates are not specific for psychosis [ 97 ] and some undesired outcomes, such as decreased social functioning, quality of life, and occupational performance, are shared across mental disorders [ 98 , 99 ], a hybrid strategy has been suggested in at-risk states involving symptom relief coupled to a reduction of transition [ 97 ]. In particular, control of symptoms and self-control of emotion and behavior as well as programs targeting poor social problem solving, low quality of social support, interpersonal conflict, loneliness, and other social difficulties in at-risk states may reduce the risk of progression to any mental health disorder, including bipolar disorder and depression [ 97 ].

Secondary prevention in youth mental health (clinical stage 2)

If patients progress to the manifestation of full-blown psychiatric symptoms, it is paramount to actively work towards securing early and possibly complete recovery, by reaching a clinical and functional remission state. Secondary preventive strategies and early intervention services aim at mitigating the occurrence of negative prognostic factors such as long duration of untreated illness, poor treatment response, poor psychosocial well-being and functioning, comorbid substance use, and high burden on patients’ families, with the final goal of preventing relapse or incomplete recovery [ 90 ]. In order to improve the effectiveness of early intervention in mental health, a Cochrane systematic review has confirmed the need for greater collaboration between primary care sector and specialist mental healthcare services [ 100 ]. In this regard, ‘consultation-liaison’ and ‘collaborative care’ models seem to work better than the so-called ‘replacement model’, where primary care physicians make simple referrals to mental health services [ 100 ], for a number of youth-onset psychiatric disorders including depression [ 101 , 102 , 103 , 104 ], psychosis [ 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 ], bipolar disorder [ 118 , 119 ], and panic disorder [ 120 , 121 ], with promising evidence for generalized anxiety disorder, social phobia [ 122 ], and somatoform disorders [ 123 ].

These multicomponent intervention programs involve the delivery of pharmacological and psychosocial interventions, as well as psychoeducation and skills training. However, disappointing evidence from studies of the effect of collaborative care on depression indicate that the clinical improvement may not be maintained after discontinuing the multidisciplinary treatment [ 101 ]. Thus, one may speculate that discharging young people to primary care or generic mental health services, which are not designed to assist young populations in the early stages of a mental disorder, is likely to result in the erosion of the initial advantages of the collaborative care, thus not changing the trajectory and outcome of the condition. In the absence of studies assessing the longer-term efficacy of such interventions, especially in preventing poor outcome, treatment disengagement, and relapse, caution is being called [ 90 ].

Tertiary prevention in youth mental health (clinical stage 3)

Tertiary prevention represents the last opportunity to mitigate the impact of mental health problems in youth. In fact, following the manifestation of a first episode of acute psychiatric symptoms, some patients may not reach full recovery, being still symptomatic or functionally impaired. Tertiary preventive strategies aim at addressing treatment resistance, poor psychosocial wellbeing and functioning, comorbid substance use, and high burden on patients’ families, with the final goal of preventing multiple relapses and disease progression [ 90 ]. While the biological evidence for an association between multiple relapse and further deterioration is conflicting [ 124 ], research suggests detrimental psychosocial and functional consequences of each relapse [ 125 , 126 ]. The absence of validated interventions to prevent multiple relapses highlights the limited protective effect of psychopharmacological treatments in the long-term, urging the development of new strategies to avoid chronicity (clinical stage 4).

A summary of promotion and preventive interventions in youth mental health is provided in Table  1 .

Towards the development of integrated and multidisciplinary services for the young population

Over the last decade, reforming youth mental health services in the perspective of integration and collaboration between different healthcare professionals has gained increasing interest [ 127 ]. Parallel, early intervention models, initially designed to assist people with psychotic disorders, have expanded their area of intervention to mood, personality, eating, and substance use disorders [ 128 ]. Thus, it has become increasingly possible to offer multidisciplinary and integrated healthcare to young people below the age of 25 with a variety of mental health difficulties as well as support their families.

In the USA, the Massachusetts Child Psychiatry Access Project (MCPAP) promoted the creation of a statewide service favoring collaborations between primary care practices and specialized child and adolescent psychiatry services. MCPAP has a wide area of intervention including attention deficit hyperactivity disorder, depression, anxiety as well as initial psychopharmacological treatment [ 129 ]. Studies have shown that most primary care practices have enrolled in the program, increasing young individuals’ access to psychiatric services and overall satisfaction [ 130 ]. With the aim of productively integrating and enhancing collaborative care at all levels of prevention, the Massachusetts Mental Health Services Program for Youth (MHSPY) has also implemented home-based integrated clinical interventions to assist severely impaired youth with mental, social, and substance use problems as well as their families in the community. Studies have shown benefits of MHSPY interventions in terms of higher psychosocial functioning and family satisfaction as well as lower burden on services and risk to self and others [ 131 ].

In Australia, a 2006 government-funded initiative led to creation of ‘Headspace’, a multidisciplinary and integrated service offering early intervention for 12–25-year-old people with emerging mental health difficulties. Headspace has a wide area of intervention including mental health, physical health, vocational and educational support, and substance use [ 132 ]. In a decade, thanks to the creation of ‘communities of youth services’ (CYSs), Headspace has seen growing the number of its centers from 10 to more than 110, granting access to services to about 100,000 young people per year, including vulnerable, marginalized, and at-risk groups [ 8 ]. An independent evaluation of Headspace has shown positive effects of the service in terms of reducing suicide ideation, self-harm, and number of absent school or work days [ 133 ].

This healthcare model is transferred to other countries at an increasingly rapid rate. In Ireland, services called ‘Headstrong’ and ‘Jigsaw’ have developed, proving to be effective in facilitating access to community care to people aged 12–25 with emerging mental health difficulties [ 134 ]. In the United Kingdom, a youth-based mental health service called ‘Youth space’ has implemented integrated health benefits for people aged 0–25 years in the Birmingham catchment area [ 135 ]. Similar models have been developed or under construction in Denmark, Israel, California, Canada (the ACCESS, Adolescent/young adult Connections to Community-driven Early Strengths-based and Stigma-free services), British Columbia (‘The Foundry’ model), and the Netherlands (@ease) [ 8 ]. Interestingly, research is following suit, with programs moving from the early identification of states immediately preceding psychosis onset in late adolescence or early adulthood to the investigation of earlier phases of illness in vulnerable children and younger adolescents (e.g. London Child Health and Development Study) [ 136 ].

In summary, a mix of services is offered among these models of care, in order to target mental health and behavior, situational problems, physical or sexual health, alcohol or other drugs use, and vocational issues. Depending on the presenting concern, the proportion of each delivered service can vary as well as the main service provider (general practitioner, psychologist, allied mental health etc.) and funding source [ 137 ]. Moreover, elements indicating best practice have been identified, including being highly accessible (affordable, convenient, timely, non-stigmatizing, flexible, inclusive, and awareness raising), acceptable (youth-friendly, confidential, respectful, engaging, responsive, competent, and collaborative), appropriate (early intervention focused, comprehensive, developmentally-appropriate, suitable to early stages of illness, suitable to complexity of presentation, evidence-based, and quality assured), and sustainable (community-embedded, integrated within a national network, effectively managed, advocate for young people’s wellbeing). These elements represent a framework to be used to inform future development, performance indicators, and standards of care [ 138 ].

Even though the topic is not covered in this reappraisal, for the sake of completeness Fig.  3 shows the next steps that would be required to vertically and horizontally integrate this enhanced model of primary care with more specialized and intensive services as well as other components of the health and social system.

Vertical and horizontal integration of the enhanced model of primary care for mental health

Conclusions and future directions

In order to guarantee youth a healthy mental development through promotion, prevention, and early interventions, research evidence supports the implementation of healthcare systems integrating mental, primary, and social care [ 128 ]. The recent implementation of mental health services for the 0–25 age span [ 8 ] poses new questions about what is needed now for this model of care to fulfill its potential. The continuity of youth mental health needs from an early age seems to go beyond the boundaries of what falls within the mental health professionals’ competences and duties, putting at stake the epistemological status of psychiatry. The mental health care sector has among its prerogatives the provision of effective interventions from early stages of illness to long-lasting conditions. However, it is increasingly clear how crucial is to deliver sustained early intervention across all potential stages, including the preclinical one, in order to avoid intermittent support and not to lose initial progresses. So, what do mental health professionals have to do? Medicalize potentially serious problems at the preclinical stage? Potentiate the social management of at-risk conditions? Both? In the mental health field, attempts of reductio at unum have left much to be desired in all ages, highlighting the greater complexity of the question. The recent debates about renaming mental health conditions or recognizing new ones on the basis of research evidence, far from being a mere hermeneutic or linguistic issue, underline the difficulty of managing what, through decades of clinical research, is emerging below the tip of the iceberg [ 139 ]. Promotion and prevention in mental health are not necessarily responsibility of mental health professionals alone. Research evidence summarized in this review suggests that health researchers and professionals as well as health service institutions and governments have to join forces to deliver integrated and multidisciplinary actions in mental health, especially in the early steps of the prevention chain. Mental health professionals have anyway the scientific, ethical, and moral responsibility to orient social, political, and overall health care actors involved in promotion and maintenance of mental health status.

Availability of data and materials

Not applicable.

Abbreviations

Adolescent/young adult Connections to Community-driven Early Strengths-based and Stigma-free services

Clinical high-risk mental state

Communities of youth services’

Disability-adjusted life-years

Massachusetts Child Psychiatry Access Project

Massachusetts Mental Health Services Program for Youth

Ultra-high risk

United States of America

World Health Organization

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• > Prevention and Youth Crime
• > Integrated or targeted youth support services: an essay on ‘prevention’

Book contents

• Frontmatter
• Acknowledgements
• List of abbreviations
• Notes on contributors

Introduction

• 1 Integrated or targeted youth support services: an essay on ‘prevention’
• 2 Intervening in gang-affected neighbourhoods
• 3 Family intervention projects and the efficacy of parenting interventions
• 4 Early intervention and prevention: lessons from the Sure Start programme
• 5 Attachment research and the origins of violence: a story of damaged brains and damaged minds
• 6 Early intervention in the youth justice sphere: a knowledge-based critique
• 7 European perspectives on prevention

1 - Integrated or targeted youth support services: an essay on ‘prevention’

Published online by Cambridge University Press:  25 March 2023

There is a lot of mischief within the debate on the respective merits and effectiveness of ‘universal’ versus ‘targeted’ services – of any kind. This is, of course, not a new debate; it has been around since the beginning of state-provided welfare services. Two burning issues have always informed that debate: one is concerned with the best use of scarce resources, the other with reaching the ‘target’ group. The two are intertwined: too much prescription and expectation about ‘measuring’ how effectively resources have been used is likely to produce what is sometimes described as ‘perverse behaviour’, in that providers will cherry-pick from within a broad target group (or even outside it) in order to optimise their chances of fulfilling the criteria on which they are being measured. This is what has been referred to, somewhat facetiously but with considerable accuracy, as ‘hitting the target but missing the point’.

The point is that, in relation to any ‘target’ group but here in the context of young people, services should actually reach and have the desired impact on them. Over the past decade or so, this has produced a particularly polarised debate between, on the one hand, some sections of what might be called the traditional youth service, which has continued to advocate for universality, and, on the other hand, new policy approaches such as youth crime prevention. The latter makes its case on the basis of quasi-scientific assessments of ‘risk’ in order to identify those who should be the priority recipients of its interventions. In England, the now somewhat discredited Connexions Service sought to find a path between the two, using the rather cleverly constructed mantra about providing a ‘universal service differentiated according to need’, thereby being accessible to all but focusing its practice at the sharp end on young people most in need of its support – which, in its policy context, were those young people not in education, employment or training (NEETs).

Beyond the rhetoric of Connexions, the battle lines have been drawn, with strategies for attack and defence on both sides. The universalists argue their moral high ground of voluntary engagement, educative and developmental intent, and person-centred approaches. They attack the opposition for labelling and stigmatising young people and, of course, for missing some of those most in need because they do not fall into technically constructed frameworks of assessment.

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• Integrated or targeted youth support services: an essay on ‘prevention’
• By Howard Williamson
• Edited by Maggie Blyth , Enver Solomon
• Book: Prevention and Youth Crime
• Online publication: 25 March 2023
• Chapter DOI: https://doi.org/10.46692/9781847422644.003

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Why Do We Need DAWN?

What is dawn, the dawn study, what dawn taught us, implications of the dawn study, translating goals into action, article information, the diabetes attitudes, wishes, and needs (dawn) program: a new approach to improving outcomes of diabetes care.

The DAWN International Advisory Committee includes Ib Brorly (a person with diabetes), Denmark; Ruth Colagiuri, RN, Australia; P. Geelhoed-Duijvestijn,MD, the Netherlands; Hitoshi Ishii, MD, Japan; Line Kleinebreil, MD, France;Rüdiger Landgraf, MD, Germany; Torsten Lauritzen, MD, Denmark; David Matthews, MD, United Kingdom; A. Ramachandran, MD, India; Richard Rubin, PhD,United States; and Frank Snoek, PhD, the Netherlands.

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Soren E. Skovlund , Mark Peyrot , on behalf of the DAWN International Advisory Panel; The Diabetes Attitudes, Wishes, and Needs (DAWN) Program: A New Approach to Improving Outcomes of Diabetes Care. Diabetes Spectr 1 July 2005; 18 (3): 136–142. https://doi.org/10.2337/diaspect.18.3.136

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The Diabetes Attitudes, Wishes, and Needs (DAWN) program is an international partnership effort to improve outcomes of diabetes care by increasing the focus on the person behind the disease, especially the psychosocial and behavioral barriers to effective diabetes management. DAWN was initiated by an international survey of > 5,000 people with diabetes and almost 4,000 diabetes care providers. The DAWN program has facilitated a number of concrete initiatives to address the gaps in diabetes care identified by the DAWN study.

Diabetes is one of the major world health problems. Recent estimates from the World Health Organization predict that if current trends continue, the number of people with diabetes will more than double, from 176 to 370 million people by 2030. 1   Diabetes is already the single most costly health care problem in Westernized countries. Among those diagnosed with the disease, at least half still do not achieve satisfactory glycemic control, despite the availability of effective treatments. 2   As a consequence, millions of people with diabetes are at elevated risk of suffering needlessly from serious complications of the disease. With the growing number of people with diabetes, there is an urgent need to find better ways of curbing the human and economic burden of this chronic progressive disease, through prevention, detection, and treatment. A review of the literature suggests several important areas that have the potential to address these problems.

Suboptimal diabetes self-management has been identified by several studies as one of the possible causes of poor outcomes of diabetes care in general practice. 3 , 4   A multitude of research studies, mainly in the Western world and with relatively small patient samples, has indicated the potential importance of a multitude of psychological, social, and behavioral factors for patient self-management. 5 , 6   Access to patient-centered self-management support and education has been shown in several studies to improve outcomes of diabetes care. 7  

Psychosocial research points to an integral role of psychosocial issues in all aspects of diabetes care, 8   and in particular comorbid depression is associated with impaired self-management and metabolic control. Psychological treatment may help to improve both quality of life and diabetes self-management. 9   Furthermore, monitoring of psychological health may improve patient-reported outcomes as part of ongoing diabetes care. 10  

In terms of the structure and processes of care, effective communication between patients and providers has been suggested to be important for optimal treatment outcomes. 11 , 12   For instance, application of motivational interviewing techniques has been shown to improve the success rate of behavior change consultations. 13  

Access to a coordinated interdisciplinary diabetes care team to offer appropriate care, whether the need is self-management education, medical advice, or psychosocial support, has been identified as an important factor for improving treatment outcomes in diabetes. 14 , 15  

Delayed initiation of medication therapies to prevent long-term complications is commonly observed in general practice settings. Both patient and provider beliefs appear to contribute to the delayed use of effective therapy (e.g., misconceptions of the consequences of initiating medication,that medication is not efficacious or may have serious side effects). 16 , 17   These factors lead to a reluctance to intensify treatment regimens, which may be overcome through improved communication.

DAWN is an international collaborative program initiated in 2001 by Novo Nordisk in partnership with the International Diabetes Federation and an international expert advisory panel representing leading spokespeople for medical, educational, psychological, and advocacy issues related to improving a person-centered approach to diabetes care. Panel members were from Denmark,France, Germany, India, Japan, the Netherlands, the United Kingdom, and the United States. National activities are developed by multidisciplinary national expert groups drawing on relevant best practices for putting DAWN into action.

The goal of DAWN is to improve outcomes of diabetes care by increasing the focus on the person behind the disease, especially the psychosocial and behavioral barriers to effective diabetes management. DAWN was initiated by an international study designed to identify a broad set of attitudes, wishes, and needs among diabetes patients and care providers (physicians and nurses) in order to lay a foundation for national and international efforts to improve diabetes care. 18   The DAWN study examined several factors related to quality of diabetes care:levels of diabetes self-management and psychological distress among people with diabetes, quality of relationships between people with diabetes and their care providers, collaboration among diabetes care providers (team care), and barriers to effective medication therapy for diabetes.

Once the DAWN study was completed, the results provided the impetus for a number of initiatives designed to remedy the problems identified. Some of these initiatives were already underway, and the results stimulated support for their development; other initiatives grew out of the collaborative efforts of the international community exposed to the findings of the DAWN study.

All data are self-reports gathered during 2001 by structured interviews conducted face-to-face or by telephone, using DAWN questionnaires that had been developed based on a literature review and focus groups in eight countries and translated into the languages of the countries studied. Interviews were conducted in 11 regions (representing 13 countries):Australia, France, Germany, India, Japan, the Netherlands, Poland, Scandinavia(Sweden, Denmark, and Norway), Spain, the United Kingdom, and the United States. The Scandinavian samples were evenly divided among the three countries.

The study was conducted with three independent samples. The first sample consisted of 2,705 physicians with a quota of 250 per region: 200 in primary care and 50 specialists (endocrinologists and diabetologists with 2 years of experience and treating > 50 diabetes patients per month). The second sample consisted of 1,122 nurses with a quota of 100 per region: 50 specialists (treating > 50 people with diabetes per month) and 50 generalists. Caring for at least five people with diabetes per month was an inclusion criterion for the study, and only one provider was selected from a given practice.

Physician respondents were predominantly male (72.6%), whereas nurses were predominantly female (95.2%). Both physicians (69.5%) and nurses (69.0%)worked in urban sites, as opposed to rural and suburban sites. Physicians had a longer average duration of practice (15.9 years) than nurses (10.6 years).

The third sample consisted of adults with type 1 or type 2 diabetes with a quota for each region of 250 people with self-reported type 1 diabetes and 250 with self-reported type 2 diabetes. For the purpose of analysis, people were classified as having type 1 diabetes if they were diagnosed with diabetes before age 40 and treated with insulin both at diagnosis and at the time of the survey; others were classified as having type 2 diabetes. Respondents who did not provide information necessary to classify type of diabetes according to this algorithm were deleted from the analyses, leaving a usable sample of 5,104.

People with diabetes were divided almost equally by sex (54.0% female) and lived primarily in urban areas (58.0%). The median age at which formal education was completed was 17 years. Approximately one-third were classified as having type 1 diabetes; Japan was an anomaly with < 5% having type 1 diabetes. Compared to people with type 2 diabetes, those with type 1 diabetes had a younger average age (38.0 vs. 59.3 years) and a longer average duration of diabetes (19.2 vs. 11.2 years).

The results reported here draw on a number of forthcoming articles and analyses presented at research conferences. 19 – 25  

Reported adherence with recommendations for diet, exercise, medication taking, glucose testing, and appointment keeping was low. Fewer than one in five people with diabetes (19.4% of those with type 1 diabetes and 16.2% of those with type 2 diabetes) reported that they completely complied with all aspects of their prescribed regimens. Providers rated adherence substantially worse than did people with diabetes (7.3% of providers estimated that their typical type 1 patient completely complied with all aspects of their prescribed regimens, and 2.9% of providers estimated the same for their typical type 2 patient).

People with diabetes reported that diabetes-related distress is high at diagnosis (85.2% reported feeling shocked, guilty, angry, anxious, depressed,or helpless). Long after diagnosis (mean duration of almost 15 years),problems of living with diabetes were prevalent, including fear of future complications and resulting social disabilities, as well as immediate social and psychological burdens ( Table 1 ). Three of four (73.6%) reported at least one of these fears or burdens. Providers reported that the majority of their patients with type 1 or type 2 diabetes experience psychological problems (67.9 and 65.6%,respectively). Almost half of all people with diabetes in the DAWN study had poor well-being according to the WHO-5 well-being index. 19  

Percentage of Patients Experiencing Various Aspects of Diabetes-Related Distress

There was a linkage between poor adherence and psychological problems. The majority of providers (68.3%) reported that psychological problems influence regimen adherence. Moreover, a poor reaction at diagnosis (characterized by an inability to accept the diagnosis and a strong negative emotional response)was associated with a variety of poor patient-reported outcomes, including regimen nonadherence ( Figure 1 ).

Despite the widespread prevalence of diabetes-related distress and its important negative consequences, only a small minority of people with diabetes(3.3%) had received psychological treatment for diabetes-related problems within the 5 years prior to the survey.

Patient-Provider Relationships

The quality of patient-provider relationships was rated high by patients;88.8% reported that they have a good relationship with the people who care for their diabetes. However, most providers reported that they need to better understand the psychological consequences of diabetes (69.8%) and the various ethnic cultures that they deal with (78.8%).

Provider Collaboration

Team care was less than optimal ( Table 2 ). To assess levels of team care, physicians were asked how many of seven providers a typical patient of theirs saw on an annual basis (primary care practitioner, diabetes specialist physician, diabetes nurse,dietitian/nutritionist, eye doctor, foot doctor, behavioral specialist). Most providers (65.6%) said their diabetes patients saw two or fewer providers in addition to themselves; specialist physicians were more likely than primary care physicians to report four or more additional providers (22.0 vs. 12.0%). Annual appointments were common only for eye doctors (approximately two or three respondents described such visits as typical), and typical appointments with most other providers were reported by only one in three participants,with behavioral specialists reported as team members for the typical patient by < 10% of physicians. Only half of people with diabetes (51%) felt that their diabetes health care providers talked to each other about their care.

Percentage of Physicians Reporting That Their Typical Patient Sees Various Diabetes Care Providers Annually

Poor reaction to diagnosis predicts later problems. QoL, quality of life.

Barriers to Use of Effective Medication Therapy

Many people with diabetes have worries about starting diabetes medication and intensifying existing medication regimens. And providers are not eager to use medication to achieve treatment goals. Of those taking antihyperglycemic medication, one in six (16.6%) feels that their treatment is too complicated,and one in three (33.7%) is tired of complying with their medication regimen. Of those not taking insulin and who feel that their diabetes is not well controlled, only one in four (26.9%) believes that insulin would help them to manage their diabetes better. Nearly one in two providers (43.4%) prefers to delay initiation of oral medication until it is “absolutely essential.” And only half (49.2%) of health care providers believe that earlier use of insulin would decrease the overall cost of diabetes care. Patients who are resistant to effective medication regimens and who are treated by providers who share their resistance are likely to experience delays in the intensification of treatment even in the face of persisting need.

The DAWN study has identified several important gaps in the management of diabetes across a number of countries. Diabetes self-management is less than optimal and is compromised frequently by diabetes-related distress, which often is not treated. Although the quality of patientprovider relationships is generally good, providers need a better understanding of the social and psychological problems that people with diabetes face. Team care is uncommon,with few providers providing their patients with comprehensive multidisciplinary care. People with diabetes and health care providers often resist initiating effective medication therapies. These problems combine and reinforce one another, leading to an unnecessary increase in the burden of diabetes.

While these findings confirm what many diabetes health care professionals already believe, the DAWN study provided the first quantitative data from a large-scale, international study regarding both the magnitude and nature of these problems. Furthermore, the study offered a host of new insights about concordance and the lack thereof in the perceptions of different participants in diabetes care. Importantly, the study identified major gaps in the provision of diabetes care today, including a failure to take fully into account the individual barriers to achieving full health and quality of life among people with diabetes.

To transform the wealth of insights from the DAWN study into concrete actions to improve diabetes care, two international DAWN summits were held,each attended by > 100 leading health care professionals, researchers,decision-makers, people with diabetes, media personnel, and representatives of major nongovernmental diabetes organizations and the pharmaceutical industry. The 1st International DAWN Summit was held in Oxford, United Kingdom, in April 2002. 26   This 2-day meeting involved presentation and discussion of the primary DAWN findings. Major themes were identified through discussion of findings in discipline-specific and country-specific break-out groups.

The 2nd International DAWN Summit was held in London in November 2003 with a goal of initiating concrete action. 27   The 2-day meeting included presentations from government policymakers, representatives of the International Diabetes Federation and the World Health Organization,and leading researchers. The common theme was defining feasible actions that could be taken to address the gaps in diabetes care identified by the DAWN study. Best practices were shared by speakers from countries that had already taken action based on the DAWN findings at a national level. These presentations laid the foundation for multidisciplinary, multinational workshops in which participants could identify concrete and feasible actions that could be taken to help overcome the barriers to optimal health and quality of life faced by people with diabetes. In plenum, voting systems enabled all participants to take part in the final selection of key goals for future action. Based on the key findings of the DAWN study, the following five goals were confirmed for concerted advocacy and action to improve diabetes care worldwide ( Table 3 ). 27 , 28  

Promote active self-management.

Active self-management is a key determinant of treatment outcome in diabetes, and therefore the diabetes care team's ability to facilitate active self-management and patient involvement in the care process is central to achieving optimal treatment outcomes. Health care professionals should encourage better self-management by taking into account individual patient's circumstances, needs, and resources when creating treatment plans and considering psychosocial barriers to self-management as an integral part of the care process.

Enhance psychological care.

Although many people with diabetes cope well and live normal, healthy lives with diabetes, far too many suffer emotionally without receiving basic psychosocial support. Improved access to health care professionals and psychologists trained in identifying patients' needs and providing counseling and psychosocial support to people with diabetes is needed in order to diminish the psychological burden of living with diabetes and overcome the psychological barriers to effective disease self-management.

Enhance communications between people with diabetes and health care providers.

Effective patient-centered communication is considered a prerequisite for understanding and addressing the individual psychosocial barriers to diabetes self-management in daily care. Because enhanced communication requires the active involvement of both the person with diabetes and health care professionals, efforts in this area should involve initiatives to empower and engage both people with diabetes as well as health care professionals to communicate effectively. People with diabetes should be supported in taking responsibility for their own disease and expressing their treatment and support needs clearly to their health care professionals.

Promote communication and coordination between health care professionals.

Diabetes is a complex condition, and its effective management requires a coordinated multidisciplinary care approach. The role of every team member should be enhanced, and strategies are needed to promote team building and dialogue among all diabetes professionals to ensure a coherent, integrated approach to optimizing treatment.

Reduce barriers to effective therapy.

Patient understanding of the consequences of not treating diabetes optimally requires that health care providers give the information and support necessary to enable patients to make informed decisions about intensification of therapy. All health care professionals should be aware of the health implications of postponing necessary therapy and should enable patients to make genuinely informed choices about therapy. This requires increased awareness and information about diabetes treatment options that suit the individual lifestyle and treatment needs of each patient.

DAWN Goals and Strategies

The DAWN Call to Action 27 , 28   was developed on the basis of international dialogue among patients,educators, physicians, health care researchers, politicians, and nongovernmental organizations. It identifies concrete strategies that can be implemented at the local, regional, national, and international levels to promote the achievement of the five goals of the DAWN program and the translation of DAWN study insights into real quality-of-life improvements on a large scale ( Table 3 ). Guided by this framework, numerous initiatives have been proposed and implemented by groups and organizations in different countries. Below, we define the strategies and provide examples of these initiatives.

Strategy 1. Raise awareness and advocacy.

Those individuals and organizations with an understanding of the benefits of providing psychosocial support for people with diabetes must play an active role in sharing their knowledge with their peers and raising awareness in the public about the importance of changing our approach to diabetes care and focusing more on the attitudes, wishes, and needs of people with diabetes and their caregivers.

Examples of action. The International Diabetes Federation (IDF)published a special issue of its journal Diabetes Voice , which was distributed in 140 countries; this issue was dedicated to the implications of the DAWN study and the resulting international DAWN Call to Action and triggered many new DAWN activities. 28   In the United States, the American Diabetes Association's patient magazine, Diabetes Forecast , highlighted the key insights from the DAWN study,reaching millions of readers nationwide. 29   In the Arabic world, Asia, Europe, and Latin America, lay media coverage of DAWN findings has helped reach out to millions more people at risk for and with diabetes.

Strategy 2. Educate and mobilize people with diabetes and those at risk.

People with diabetes and those at risk of developing the condition need access to empowering information in order to make informed decisions about their health and quality of life. As experts in the management of their own condition, people with diabetes need to be engaged to play a key role in new approaches, tools, and guidelines for patient-centered care. People with diabetes inform health care providers, policymakers, and others about the needs and wants of people with diabetes.

Examples of action. The Assisting Young Diabetics in Egypt Project successfully offered psychological support and therapeutic patient education to > 2,000 children and families with diabetes over just 2 years' time. This project was identified by the DAWN international advisory board as the winner of the 2004 DAWN Award. The DAWN international and national advisory boards involve people with diabetes, and the DAWN summits offer people with diabetes opportunities to speak to international audiences about their needs. In Germany and the Netherlands, concrete activities include the issuance of diabetes passports to all people with diabetes to encourage active self-management and clear communication and agreement among patients and providers about the mutual responsibilities involved in optimal diabetes management. In New Zealand, people with diabetes attending a large diabetes center were offered a patient involvement form before each consultation to encourage active patient participation and clear communication during diabetes visits.

Strategy 3. Train health care providers and enhance their competencies.

In order to overcome the psychosocial barriers to effective diabetes management identified by DAWN, health care systems need to identify ways to improve the identification of these barriers and develop approaches to effectively address these in general practice settings. Training opportunities should be made more easily available for diabetes health care providers, along with simple and practical strategies to promote sustainable institutionalization of feasible person-centered approaches to delivering diabetes care.

Examples of action. In the United States, a continuing medical education program on how to put DAWN into clinical practice was created for diabetes educators based on one of several DAWN symposia held as part of the annual meetings of the American Association of Diabetes Educators. 20   In Poland, the DAWN study revealed a major national need for training primary care in an integrated medical and psychosocial approach to treating type 2 diabetes. Using DAWN as a foundation, train-the-trainer workshops and simple daily assessment tools were developed and disseminated widely in that country,and today > 4,500 Polish health care professionals have been trained in both the psychological and medical aspects of treating diabetes. In Germany,> 1,000 general practitioners, and diabetes specialists and nurses were trained in skills focusing on communication and psychosocial matters in order to increase patient empowerment. Drawing on experiences from > 300 diabetes nurse specialists from 14 countries who took part in a new DAWN workshop concept for diabetes teams, a set of diabetes team workshops and DVD- and video-enhanced training tools was developed in 2004; these have been adopted by many providers in countries such as Australia, Germany, Israel, Sweden, the United Kingdom, and the United States.

Strategy 4. Provide practical tools and systems.

The adequate identification of psychosocial and educational needs requires first and foremost effective listening and communication skills on the part of health care professionals, an essential element of the chronic illness care model. 30   In addition, patient self-report assessment tools and decision-support tools can facilitate inclusion of psychosocial aspects in routine clinical encounters between health care professionals and patients to improve patients'well-being. 10 , 31  

Examples of action. In response to the DAWN study, several countries have introduced internationally endorsed measures of psychological well-being,diabetes-related distress, and barriers to self-management into quality-of-care monitoring systems. During the period from 2002 to 2004, >15,000 people with diabetes from > 15 countries have completed the WHO-5 well-being index and other diabetes-specific items from the DAWN survey questionnaire, offering a wealth of new insights about the needs of people with diabetes and the associations between psychological variables, perceived quality of care, and clinical outcomes. A one-page patient form was developed in New Zealand and several other countries for use by patients prior to each consultation to help identify relevant psychosocial issues and promote more active involvement of the patient in the consultation and decision-making process.

Strategy 5. Drive policy and health care systems change.

In diabetes management guidelines, reimbursement systems, and quality systems, the psychosocial needs of people with the condition should be approached with the same priority as their medical needs. Toward this end,governments and health care systems can be lobbied to adopt the chronic care model advocated by the World Health Organization.

Examples of action. The DAWN program has facilitated two international guideline meetings in 2004 and 2005 aimed at promoting consensus regarding evidence-based recommendations for psychosocial care for people with diabetes. At the DAWN guideline meeting in Wuerzburg, Germany, in April 2005,experts in psychosocial aspects of diabetes from 12 different countries developed a joint statement that “diabetes mellitus is an emotionally and behaviorally demanding condition, and psychosocial factors are integral to its prevention, diagnosis, treatment, and outcomes.”

In response to the DAWN Call to Action, the national care guidelines in Japan were updated to include psychosocial treatment recommendations for diabetes, and the Psychology and Behavioral Medicine Council of the American Diabetes Association initiated a working group to develop psychosocial care guidelines. In 2003 and 2004, the Netherlands and Germany have taken steps towards implementing evidence-based psychosocial guidelines in diabetes, 32   and the IDF will be publishing its global treatment guideline by the end of 2005 with a separate section on psychosocial care in diabetes.

Strategy 6. Develop psychosocial research in diabetes.

More collaborative clinical research on psychosocial aspects of diabetes needs to be conducted to demonstrate the health and economic benefits to society of improved patient-centered diabetes care and adoption of the call to action specified here. A better understanding is required of the effective patient-centered approaches to support self-management and enhance long-term health and quality of life of people with diabetes.

Examples of action. The European Depression in Diabetes Research Consortium (EDID), a multinational research initiative stimulated by the DAWN Call to Action, has begun to assess the psychosocial burden of diabetes by promoting the use of a common set of measures so that national comparisons can be made. 33   In countries such as Argentina and Israel, evaluation studies are ongoing to assess the impact of intervention and education programs aimed at bringing the DAWN findings into action. A multicountry DAWN study in Europe is examining the feasibility of daily use of psychosocial assessments in primary care settings in Europe. In the United States, a large DAWN research initiative has been launched to evaluate specific approaches to increasing active participation in diabetes care among people with diabetes from different ethnic groups.

The paradigm for treating diabetes care is changing on a global scale. Governments, health insurers, health care professionals, and nongovernmental organizations are increasingly recognizing the importance of new partnerships and new ways of adopting more effective approaches to helping people with diabetes better self-manage the medical and psychosocial challenges associated with the disease. The DAWN study has contributed to highlighting the urgency of making this change and identifying where efforts need to be focused at the global and national levels. The DAWN program has stimulated momentum to support national action and provided a platform for sharing best practices worldwide.

A key challenge for putting the insights from the DAWN study into effect is the ongoing promotion of broad dialogue and the creation of sustainable partnerships involving all key parties in diabetes care, with people with diabetes at the center. Only through such partnerships can the proposed new approach to diabetes be fully embedded into whole communities and national diabetes programs. Furthermore, an increased focus on the attitudes, wishes,and needs of special populations (including children and adolescents with diabetes and people with diabetes in underprivileged communities or who belong to ethnic minorities) is critically needed to identify opportunities to improve care and quality of life for these groups.

Continuous and increasing collaborative efforts are needed to transform care for diabetes and other chronic diseases from the acute to the chronic care model. Future focus needs to be placed on implementation and translational research, with international sharing of effective tools for furthering a person-centered approach to chronic disease management and prevention.

Soren E. Skovlund, Msc, Bsc, is a senior adviser at Novo Nordisk in Bagsvaerd, Denmark. Mark Peyrot, PhD, is a professor of sociology at Loyola College in Baltimore, Md.

Note of disclosure: Mr. Skovlund is employed by and Dr. Peyrot has received honoraria and research support from and served on an advisory panel for Novo Nordisk, which manufactures products for the treatment of diabetes and has provided financial support for the DAWN initiative.

The DAWN study was initiated and funded by Novo Nordisk, which provided access to the data presented in this article and support for its writing. Aggregate country-specific data may be made available for local quality-of-care improvement activities. (See www.dawnstudy.com .)Novo Nordisk has provided ongoing support for the DAWN program, including DAWN summits and various national DAWN initiatives.

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Libya, Intervention, and Responsibility: The Dawn of a New Era?

Peace Diplomacy, Global Justice and International Agency: Rethinking Human Security and Ethics in the Spirit of Dag Hammarskjold, Carsten Stahn and Henning Melber (eds.), Cambridge: Cambridge University Press, 2013, Forthcoming

Posted: 20 May 2013

Noemi Gal-Or

Kwantlen Polytechnic University

Francis Abiew

Date Written: 2013

Following the United Nations (UN) Security Council (SC) Resolution 1973 of 17 March 2011, which authorized the use of military force, coalition forces began air strikes against Libya to implement the no-fly zone. Carried out by NATO, the resolution was subsequently interpreted as also mandating the removal of Gadhafi. The paper examines two questions fundamental to the United Nations’ trajectory for the 21st century: Does Resolution 1973 (2011) represent a classic case of humanitarian intervention? Or, does the resolution represent – as some pundits have been arguing - the first ever demonstration of the decade long ‘emerging’ norm of the Responsibility to Protect (R2P)? Did the resolution indeed trigger the international legal duty to protect civilians under threat to their ‘human security’? And if so, can we expect similar UN resolutions and missions in the future? We argue that while a case could be made for this case-study as an instance of the legal validity of humanitarian intervention, its legal precedent-setting nature in terms of R2P is doubtful.

Keywords: Libya, Intervention, International, Conflict

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Noemi Gal-Or (Contact Author)

Kwantlen polytechnic university ( email ).

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PAKISTAN’S MOMENT OF YOUTH

The future of Pakistan — good or bad — will be determined by its young; most especially by those who are between 15 and 29 years of age today.

This, of course, is a cliché. But it happens to be a cliché that is quite literally true. Here is why.  Pakistan’s ‘youth bulge’ is palpable. Just over two out of every three Pakistanis today are below the age of 30 and just under one in every three is between 15 and 29 years of age (our definition of youth).

What the demographic momentum imbedded in this one statistic implies is that Pakistan is not just a young country, but that it is going to remain young till at least to 2050, possibly longer.  More importantly, my own research suggests that the youth of Pakistan know this and they expect being given the attention and respect this demographic reality demands.

Others who have looked at the question have come to similar conclusions. But the fact of the matter is that we do not need statistics to tell us that Pakistan is a young country. You just need to look around you. Any street. Any marketplace. Advertising on your television set. Certainly, on your Twitter feed. Any political jalsa [gathering]. Any office. Even elected officials and unelected political influentials.

The generational change is not on its way. It’s here. It’s set. And, most importantly, it’s here to stay. At least for, and probably for more than, the next two decades.

With the majority of Pakistan’s population below the age of 30, the young will invariably influence the country’s future trajectory. However, where the youth of today take this country will depend on the choices that today’s policymakers, Pakistani society and the young themselves make. Eos presents an excerpt from an essay by Adil Najam from the book Pakistan: Search for Stability, published by Oxford University Press…

BEING YOUNG IN PAKISTAN

In 2017, the Pakistan Human Development Report produced a comprehensive profile of youth in Pakistan, including a wealth of empirical and opinion data on the young, collected from an estimated 130,000 Pakistanis. However, the key question that we, the authors of the report, were most concerned with was “what does it mean to be young in Pakistan?”

Not surprisingly, no easy answers were forthcoming. Like so many other places in the world, being young in Pakistan is both exciting and frustrating. The space that the young occupy in Pakistani society is vast and full of possibilities but, in their own words, is often described as crumbling, contested and constrained on the one hand, and uneven, unfair and uncertain on the other.

It is a space that is defined by high hopes, but also deep fears. As subsequent research and events have confirmed, to be young in Pakistan is to be highly agitated, and very often angry. Our research does begin pointing out some of the reasons why this is so.

For example, if you were to computationally condense the over 60 million young Pakistanis aged between 15 and 29 into a statistically representative one hundred young people, you would find that just 30 of them consider themselves to be functionally literate, 29 would never have gone to school (despite all being 15 or above), only 6 would have 12 or more years of education and just 39 would be employed.

More telling, however, are the structural depravations which highlight that the space ‘to be young’ is severely constrained and shrinking. Of the 100, only six would have access to a library, only seven to a sports facility, just 21 to a park. Only three would have ever been to a cinema, only three to a live music performance. Fifty-nine would say that they do not play sports, or only infrequently.

One in the 100 would own a car, 12 a motorcycle, 10 a bicycle and 77 would have no means of personal mobility. Each of these depravations becomes even more acute for women, rural youth, and other marginalised groups within the young.

And, yet, within this notional 100, we also found a spirit of great national pride, high aspirations, much hope, and tremendous expectations. They were eager to announce, to any who wish to ride the tiger of Pakistan’s youth, to never forget that this is a generation that demands and deserves better. They are politically excited, excitable and astute.

While only 24 percent said (in 2016) that they trusted political leaders, 90 percent of young men and 55 percent of young women claimed that they would vote in the next elections. Of every 100, 48 believe that Pakistan’s future will be bright — although 36 fear it will be bleak.

Most tellingly, 67 [of the 100] believe that their lives are and should be better than their parents, only 15 expect themselves to be worse-off than their parents; 89 say they feel happy; 70 say they feel safe. All of them demand the space and conditions in which they can achieve their aspirations.

In short, the world of young Pakistanis is as diverse, as differentiated, and as divided as the rest of Pakistan. However, they also have greater expectations and aspirations which, if nurtured, could yield high dividends. Much more telling, however, is the palpable impatience and restlessness which, if ignored, could result in disaster.

There are three things to keep in mind as we think about youth anywhere in the world, but certainly in the context of Pakistan.

First, and most importantly, youth is a defining category. The reason to think of the young as a category is not just because they are so many, but because — even if they were not this many — the 15-29 year age bracket is where ‘citizenship’ matures.

Second, youth is fleeting. Analytically, too, youth is a transitory and dynamic category. Because changes happen fast and furious when one is young, the definition of youth identity and what it stands for can change rapidly, even whilst within that category. Those turning 15 or 16 today can find themselves very distant from those turning 28 or 29 and will very likely not easily recognise the passions of those who would be 16 by the time they turn 28.

This may well be true for other categories too but is consequential here, because the short window of this category and the rapid changes within it make notions of what “youth believe”,  “youth stand for”,  and “youth want”, or even ideas of the “youth vote”, are much more transitory and contestable than many analysts assume, and do compound the challenges of youth representation.

Finally, youth — especially in Pakistan — is an extremely diverse category. At one level, any category of well over 60 million individuals cannot possibly be homogenous and would demand an investigation into its internal contradictions. But, much more than that, each of the major cleavages that exist in Pakistani society are compounded in its young: gender, class, rural-urban, wealth, technology, ethnicities, religiosity and sectarianism, and geography.  

PAKISTAN AND ITS YOUNG: THREE PROPOSITIONS

Building and extending on the available research, let us review three key propositions — political, societal and developmental — on how the young of Pakistan might influence the future trajectories of the country’s society and politics.

These propositions are offered not as predictions or scenarios, but as choice points. Embedded within each proposition are levers of possible change — where the youth of today take this country will very much depend on the choices that policymakers, Pakistani society and the young themselves make on each of these dimensions.

Proposition 1: The young of today are defining tomorrow’s politics, but not always in ways we imagine

On the face of it, the bold sounds, sights, language, and even substance of Pakistan politics today seems driven by the young. Even where mainstream political parties are still led by septuagenarians, they wrap themselves in the emblems of youth; political rallies of all parties, even religious ones, feel like high-intensity concerts; political communication is not only geared towards the young but most often crafted by them.

On the one hand, this is not entirely new, nor surprising. On the other, however, there is something palpably different, as if what would have been ‘regular’ youthfulness is now on steroids. There is significant reason to believe why it is, and will remain, so.

At a basic demographic level, all political actors realise how the maths works: the young are the single largest bloc of new and impressionable voters in Pakistan and there is a long-term and steady supply of them. The demography described in the Pakistan National Human Development Report suggests that every election in Pakistan between now and around 2050 will be defined by the youth vote — including, of course, by their choice to vote or not. 

Notwithstanding the dichotomy of young Pakistanis claiming high intent to vote and a history of not having done so in the past, the number of young entrants into the voting mix means that, mostly within two election cycles, today’s new voter would be about to — or would already have — enter(ed) a burgeoning 30-49 years middle-age category historically the most reliable and loyal voting group in Pakistan. The political logic of investing in the young voter is impeccable.

But demography alone does not explain the dominance of the youth voice in Pakistani politics today. Technology seems to have played an even more defining role; a role that is likely to be as enduring. That the rise of ‘new’ (especially social) media would trigger a steep decline of the ‘old’ (particularly print) media was probably inevitable, but the ‘control’ younger political operatives now exert over social media in all political groupings is remarkable and is now driving significant parts of the political narratives in the country.

Of course, certain leaders and parties have capitalised more on courting the youth vote than others and have been differently successful in it. This matters, but mostly in ways that it has always mattered. One should not expect permanence in youth loyalties, not least because it remains a dynamic and diverse category.  It remains to be seen if the current and emerging youth bulge will practically change ballot box behaviour, but conditions are certainly ripe to create the possibility.

Finally, a very remarkable feature of Pakistan’s emergent political discourse is how explicit mention of youth issues is nearly absent from political narratives. This, despite the feverish pitch of the political discourse, despite the active participation of the young in this discourse, and even despite the role the young are clearly playing in shaping the narratives.

A possible explanation for this anomaly could be that politically active youth in Pakistan have convinced themselves that the pathway to material benefits for themselves — particularly, for example, in the area of employment and improved living conditions — lies through the choice of political leadership rather than of policy.

Proposition 2: Give the young the ability to be young or expect a Pakistan tomorrow that is as divided as it is today

The idea that we are denying the young in Pakistan the space to be young is a major finding of the Pakistan National Human Development Report. But it is a thought that first hit me like a ton of bricks in December 2014, as I visited the New Muslim College in Charsadda — just days after the horrific terrorist attack at the Army Public School (APS) in Peshawar — to hold a focus group discussion with 15-18-year-olds on what young Pakistanis were thinking.

It struck me that the young men with me in the room were not much older than the students who had died at APS just a few days ago, or those who had done the horrific killing. The reality of the APS attack hung heavy in the room and I realised, as did they, that it is the young in Pakistan who have had to do much of the dying in the so-called ‘War on Terror.’ But there was also a palpably steely resolve in the room. Here is what I wrote about that encounter:

“Unlike every other APS conversation I had been hearing — on television, on social media, from politicians, in drawing rooms — theirs was devoid of sloganeering. There was no sign of despair. No hollow display of anger or anguish. No camouflaging of fear with bravado. Instead, there was resolve. Very endearing. Very becoming. Very mature. A very matter-of-fact recognition that this was the reality of the Pakistan they had inherited. A reality they now have to live with…”

It is then that I fully realised the perils of being young in Pakistan. “Extremists are out to indoctrinate the young. Terrorists are out to kill them. Educational institutions can neither guarantee quality education nor physical security. An emergent politics of anger uses the passions of the young as fuel for petty politicking. The result is that the space for the young to be young has shrunk — is endangered.”

My research has convinced me that the best gift that Pakistan can give to its young is to return to them the ability to be young. Indeed, it may be the best gift Pakistan can give itself — a future where this ability continues to be denied cannot be good for any Pakistani.

Being young is not just about being carefree, it is also about being able to explore. In the shrinking space to be able to do so, the young in Pakistan have already inherited most of the societal divides that define the country as a whole. That as many young Pakistanis consider being a Pakistani as their primary identity as consider their religion to be their primary identity, is probably reflective of society as a whole.

But what was the most disturbing aspect of our research was that more than 40 percent young men and 50 percent young women disapproved of having friendly relations with someone from another religion, or even another sect; nearly three out of every four young Pakistanis (men and women) responded that they would disapprove of someone from a different religion or sect preaching their religion.

The distrust that defines Pakistani society as a whole is equally prevalent amongst the young.  Just over 20 percent said they trusted politicians, only around 25 percent trust the police, just 40 percent had trust in the judiciary and less than 50 percent in the media. All of this was in 2016, and there is enough reason to believe that trust amongst the young has only eroded further since then.

Such a snapshot should be read not just as what the youth of today think, but what the Pakistan of tomorrow is likely to think. The challenges of social division, societal distrust and mutual intolerance are clearly great, but solutions are available. Silly as it may sound to some, given the enormity of the challenges, the very first — and possibly most meaningful, although not always easy — step should be resolute policy in allowing the young to be young.

Sports grounds are not a big investment, but they can be more meaningful than we might think. It is remarkable how parochial we have become, and simple steps to enhance mobility for the young, including the ability for travel exchange within the country to get to meet other Pakistanis who may not look like us but are equally Pakistanis, is another small but possibly impactful investment.

Safe and affordable mobility (along with reliable childcare and clean bathrooms) for young women, in fact, emerges as amongst the most effective means of significantly increasing women’s participation in the workforce.

Obvious as it should be by now, it is worth noting that, as we think about youth as a category for social analysis, now and into the future, the simple dichotomy of ‘young vs old’ is not only un-useful but can also be dangerous. In society, as in politics, some of the greatest and most alienating divisions that exist in Pakistan exist amongst the young themselves. The policy challenge is to find ways to reduce these divisions now before they sink deep roots and are passed on to the future, and to future generations.

The goal is not empty slogans of ‘integration’, but investing in practical means for the young in Pakistan to interact with other young people in Pakistan. Across divisions of gender, class, geography, religion and rural-urban-metropolitan, the bridges that need to be built are not just of concrete but of conversation.

Proposition 3: ‘Boom or bust?’ — it’s a choice

We began the 2017 Pakistan National Human Development Report with a story that is not from Pakistan. It remains valid and is worth repeating here:

“On December 17, 2010, a 26-year-old fruit and vegetable vendor in a small town in Tunisia set himself on fire, following a confrontation with a municipal official about where his cart was parked. While the specifics of what led to Mohamed Bouazizi’s death are unclear, what is indisputable is his fatal self-immolation catalysed protests that toppled Tunisia’s dictator and led to a string of uprisings in the region that came to be called the Arab Spring.

“The aim of mentioning this situation here is not to recount what happened in Tunis that day, or in the other countries of the Arab Spring subsequently. [Our concern is] with Pakistan’s youth. So, fast forward to Pakistan.

“Can you imagine a situation, anywhere in Pakistan, where a young person feels so frustrated by unemployment, or so disheartened, un-empowered and marginalised, that he takes a measure as extreme as Bouazizi did in Tunisia? One certainly hopes not. But hope alone is not enough. It is the responsibility of the state as well as society to enable an environment for our youth where such a fate is not even imaginable. Not even in our worst nightmares.”

Trying to predict whether Pakistan’s demographic youth momentum will end up being a ‘boom’ or a ‘bust’ is a fool’s errand. That Pakistan today has the largest number of young people it has ever had and that this number is set to grow over the next multiple decades, is a fact. How this fact will play out is not a matter of reading tea leaves, it is a matter of policy choice.

There is the inherent potential of a ‘boom’ in every youth bulge. A large number of new young entrants into the economy can become motors of consumption, generators of ideas and innovation and harbingers of new social energy.

There is also the equally inherent potential of a ‘bust’ in every youth bulge. A large number of new entrants into the economy need new employment, can feel suffocated by the lack of room to grow, and can burn with anger when existing systems they wish for are not enabled to change.

Certainly not as simple as it may sound, but the final path taken does depend on the choices made by policy, by society, and by the young themselves.

The writer is the founding dean of the Pardee School of Global Affairs at Boston University in the US and is a former vice chancellor of the Lahore University of Management Sciences (Lums).

He is currently the president of the World Wildlife Fund (WWF) International This is a slightly modified version of an extract from the book Pakistan: Search for Stability, edited by Maleeha Lodhi and published in Pakistan by Oxford University Press.

It has been excerpted with permission from the author, editor and the publisher

Published in Dawn, EOS, May 5th, 2024

Dr. Adil Najam is a professor of Earth and Environment and the Dean of the Pardee School of Global Studies at Boston University. He is a former Vice Chancellor of LUMS.

He tweets at @AdilNajam

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DAWN Youth: International Insights and Strategies Toward a Person-Centered Care Model for Young People with Diabetes

• M. Wit , F. Snoek
• Published 2009
• Medicine, Psychology

4 Citations

Recommendations for age‐appropriate education of children and adolescents with diabetes and their parents in the european union, "i just have diabetes": children's need for diabetes self-management support and how a social robot can accommodate their needs, using a robot to personalise health education for children with diabetes type 1: a pilot study., attained education and self‐assessed health later in life when diagnosed with diabetes in childhood: a population‐based study, 9 references, psychological care of children and adolescents with diabetes, monitoring and discussing health-related quality of life in adolescents with type 1 diabetes improve psychosocial well-being, adolescent diabetes management and mismanagement, a short form of the diabetes quality of life for youth questionnaire: exploratory and confirmatory analysis in a sample of 2,077 young people with type 1 diabetes mellitus, outcomes of the dawn youth summits of 2007 and 2008, updated and revised diabetes family conflict scale running title: revised diabetes family conflict scale received for publication 17 november 2006 and accepted in revised form 14 march 2007., the confidence in diabetes self-care scale: psychometric properties of a new measure of diabetes-specific self-efficacy in dutch and us patients with type 1 diabetes., follow‐up results on monitoring and discussing health‐related quality of life in adolescent diabetes care: benefits do not sustain in routine practice, assessment of eating disorders: interview or self-report questionnaire, related papers.

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