Nature Of Mental Health Problems Research Articles

How is mental health associated with adolescent alpha-amylase and cortisol reactivity and coordination?

To better understand the role of neuroendocrinological regulation in adolescent mental health, stress reactivity needs to be analyzed through both the autonomic nervous system (ANS) and the hypothalamic–pituitary–adrenal (HPA) axis. Accordingly, this study examined how adolescents’ internalizing and externalizing mental health symptoms are associated with their salivary alpha-amylase and cortisol levels, responses, and coordination (symmetry versus asymmetry). We utilized a developmentally salient stress task of mother–adolescent conflict discussion. Eighty 18–20-year-old late adolescents (55% girls) participated in a home laboratory assessment involving a 10-min conflict discussion with their mothers. Five adolescent saliva samples were collected to measure alpha-amylase and cortisol levels before, immediately after, and in 10-min intervals following the conflict discussion, to indicate stress reactivity. Adolescents had reported their internalizing (depression, anxiety, somatization) and externalizing (inattention, hyperactivity, anger control problems) symptoms 1 year earlier as part of a prospective family study. Internalizing symptoms were associated with adolescents’ high baseline cortisol levels, but not with cortisol responses or alpha-amylase levels or responses. In contrast, externalizing symptoms were associated with blunted alpha-amylase responses. Neither internalizing nor externalizing symptoms were associated with asymmetry between alpha-amylase and cortisol reactivity. The mother–adolescent conflict discussion was relevant as a stress stimulus to induce neuroendocrinological stress responses in adolescents. The nature of mental health problems was important for stress reactivity, yet, we found no evidence about mental health problems being related to endocrinological asymmetry in adolescents.

Wisdom capacities in people with and without chronic mental health problems: A representative survey on a general German adult population

Wisdom capacities are important for coping with difficult and ambiguous life situations. People with chronic mental health problems often have problems in coping with life problems. Until now, there are no comparative and representative data on the distribution of wisdom capacities people with and without chronic mental health problems. Identifying strengths and limitations in wisdom capacities in both groups will give a basis for specific focus in wisdom training in clinical settings and public health. This cross-sectional observation study examined a German population with a representative sample of 2505 persons aged 16 – 95 years in 2019. Sociodemographic data as well as chronic mental illnesses data were collected, and wisdom capacities were assessed by the 12-WD Wisdom Scale. The surveys were carried out using interviews and self-report questionnaires at the respondents’ homes by an experienced social research company. The wisdom capacities value and problem relativization, as well as emotion acceptance were scored the highest by people with and without chronic mental health problems. Uncertainty tolerance, sustainability and perspective change received the lowest scores. People with chronic mental health problems had slightly lower overall wisdom affinity (M = 7.00, SD = 1.41 on a scale of 0 – 10) as compared to mentally healthy people (M = 7.7, SD = 1.38). Specifically, persons with chronic mental health problems reported the lowest ratings on wisdom capacities requiring active cognitive reflections (sustainability, perspective change, and uncertainty tolerance). In conclusion, since there are rather small quantitative differences between persons with and without chronic mental health problems, the wisdom concept seems appropriate to be applied to all individuals, regardless of the severity and nature of mental health problems. Wisdom enhancement, for instance, by means of wisdom training, may be focused on wisdom capacities which were rated comparably low, including perspective change, uncertainty tolerance and sustainability.

BOAM: A Visual, Explanatory Diagnostic and Psychoeducation System Used in Collaboration with Families—Feasibility and Acceptability for Children Who Are Non-Responsive to Treatment as Usual

Many children referred to mental health services have neurodevelopmental problems, which are not always recognized because the resulting emotional and behavioral problems dominate diagnosis and treatment. BOAM (Basic needs, Order, Autonomy and Meaning) is a new diagnostic system consisting of imaginative models that explain the complexity of symptoms and underlying neuropsychological problems in a simple way. It is designed to be used in a transparent, collaborative process with families, so that family members can better understand the nature of mental health problems, thus increasing self-knowledge and mutual understanding. In this study, the feasibility of the BOAM diagnostic trajectory and subsequent treatment informed by this trajectory are evaluated clinically in 34 children who have not responded to or relapsed after treatment as usual (TAU). Parents completed questionnaires pre-test, post-test and at a 3-month follow-up. The treatment drop-out rate was 2.9%. Post-test, parents rated the BOAM trajectory positively. The questionnaires (measuring child psychopathology, attention, executive functioning, family functioning, partner relationships and parenting stress) demonstrated sensitivity to change, and therefore, seems appropriate for a future effectiveness study. A limitation was the high percentage of missing measurements both post-test (41%) and at the follow-up (41%). The BOAM diagnostic trajectory and subsequent treatment may be a feasible alternative for children who do not respond to or relapse after TAU.

A PRISMA systematic review of adolescent gender dysphoria literature: 2) mental health.

It is unclear whether the literature on adolescent gender dysphoria (GD) provides sufficient evidence to inform clinical decision making adequately. In the second of a series of three papers, we sought to review published evidence systematically regarding the extent and nature of mental health problems recorded in adolescents presenting for clinical intervention for GD. Having searched PROSPERO and the Cochrane library for existing systematic reviews (and finding none), we searched Ovid Medline 1946 -October week 4 2020, Embase 1947-present (updated daily), CINAHL 1983-2020, and PsycInfo 1914-2020. The final search was carried out on the 2nd November 2020 using a core strategy including search terms for 'adolescence' and 'gender dysphoria' which was adapted according to the structure of each database. Papers were excluded if they did not clearly report on clinically-likely gender dysphoria, if they were focused on adult populations, if they did not include original data (epidemiological, clinical, or survey) on adolescents (aged at least 12 and under 18 years), or if they were not peer-reviewed journal publications. From 6202 potentially relevant articles (post deduplication), 32 papers from 11 countries representing between 3000 and 4000 participants were included in our final sample. Most studies were observational cohort studies, usually using retrospective record review (21). A few compared cohorts to normative or population datasets; most (27) were published in the past 5 years. There was significant overlap of study samples (accounted for in our quantitative synthesis). All papers were rated by two reviewers using the Crowe Critical Appraisal Tool v1·4 (CCAT). The CCAT quality ratings ranged from 45% to 96%, with a mean of 81%. More than a third of the included studies emerged from two treatment centres: there was considerable sample overlap and it is unclear how representative these are of the adolescent GD community more broadly. Adolescents presenting for GD intervention experience a high rate of mental health problems, but study findings were diverse. Researchers and clinicians need to work together to improve the quality of assessment and research, not least in making studies more inclusive and ensuring long-term follow-up regardless of treatment uptake. Whole population studies using administrative datasets reporting on GD / gender non-conformity may be necessary, along with inter-disciplinary research evaluating the lived experience of adolescents with GD.

When patients and clinician (dis)agree about the nature of the problem: The role of displays of shared understanding in acceptance of treatment

Globally, 4.4% of the world's population suffer from depressive disorder, and 3.6% from anxiety disorder. Previous work found considerable negotiation between providers and patients about the nature of mental health problems and frequent patient resistance to treatment. However, how doctor-patient shared understanding of the problem is reflected in treatment recommendations and whether this is consequential for patient acceptance of treatment is poorly understood. This study explored shared understanding of the problem and patient acceptance of treatment using conversation analysis. In 52 U.K. video recorded primary care consultations (collected July 2014–April 2015), 33 treatment recommendations for medication or talking therapy were identified. Shared understanding was explored focusing on: whether the patient presented the mental health problem as their primary initial concern and how they characterised the concern; whether the mental health concern was raised by the patient; and how the doctor aligned with the patient's earlier characterisation of the problem in the treatment recommendation itself. These phenomena were coded for each treatment recommendation and the impact on treatment acceptance was explored. Patients accepted the recommendation immediately in 38% cases and actively resisted in 62% cases. However, two communication behaviors were associated with patient acceptance: recommending treatment for the patient's initial focal concern and doctors' turn design in the recommendation itself, i.e., using the patient's earlier words from the initial problem presentation to describe and characterise the problem. Given the global burden of mental health problems and frequent patient resistance to treatment, understanding how professionals can engage more closely with the patient's perspective is important. When doctors use the patient's precise words from the initial problem presentation in the treatment recommendation, this displays an understanding of the patient's perspective and personalisation of treatment based on the underlying biomedical or social causes, which then impacts on patient acceptance of treatment.

The psychological impact of implantable cardioverter defibrillators: a case study

Implantable cardioverter defibrillators are the most effective therapy available to prevent sudden cardiac death. Both depression and anxiety are common disorders in patients with implantable cardioverter defibrillators. Nurses need to recognise both mental distress and mental illness to ensure that these patients receive prompt assessment, care and management. This article discusses the nature of mental health problems in people with implantable cardioverter defibrillators and how nurses can recognise and assess them, as well as support patients.

Impact of Attitudes and Rurality on Veterans' Use of Veterans Health Administration Mental Health Services.

Veterans, especially those residing in rural areas, continue to underutilize mental health care. This longitudinal study assessed attitudes relevant to seeking mental health care services from the Veterans Health Administration (VHA) over 12 months, adjusting for residence. A questionnaire addressing attitudes, sociodemographic factors, residence, place identity, perceived health status and needs, and structural barriers was administered by telephone to 752 veterans with previous VHA service use. Service use data were obtained from a VHA database. In adjusted models, four attitudes were significantly associated with underuse of VHA mental health care (no use vs. any use; no use vs. nonsustained use vs. sustained use). Higher levels of mistrust of others (adjusted odds ratio [AOR]=1.06, p=0.046), emotional stoicism (AOR=1.08, p=0.003), belief in the self-resolving nature of mental health problems (AOR=1.91, p=0.015), and belief in the efficacy of religious counseling for such problems (AOR=1.09, p=0.022) were associated with no subsequent service use versus any use. Place identity (suburban), older age, and greater need were associated with greater odds of VHA use. For the comparison of no use versus sustained use, women had lower odds of no use (AOR=0.49, p<0.001); similarly, women had lower odds of nonsustained use versus sustained use (AOR=0.45, p<0.001). The association of potentially modifiable attitudes with underuse of VHA mental health services suggests that attitudes offer useful targets for efforts to increase mental health care use. That these attitudes were influential regardless of residence suggests that programs addressing attitudinal barriers can be broadly targeted.

Mental distress among young people in inner cities: the Resilience, Ethnicity and AdolesCent Mental Health (REACH) study

BackgroundRecent estimates suggest around 14% of 11–16 years in England have a mental health problem. However, we know very little about the extent and nature of mental health problems among...

A new approach to psychopathology: the example of depression.

What is the nature of psychopathology? The currently dominant view is exemplified in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which offers standard criteria for the classification of mental disorders.1 These criteria (that is, symptoms) are believed to be manifestations of an underlying entity (that is, the disorder), just as physical complaints are manifestations of a physical disease. This perspective is called the ‘common cause approach’ and has dominated mental health clinical practice and research. There have been several criticisms of this approach, including the questionable validity, reliability, and utility of psychiatric diagnoses.2,3 This is apparent from the striking heterogeneity in symptom profiles and course trajectories within the diagnostic categories,4,5 and high comorbidity across categories.3 Furthermore, neither neuroscience studies nor genetic studies have demonstrated biological causes convincingly.6 Another important critique is that the differential characteristics of individual symptoms and their potential causal relations are neglected.7 Finally, translating symptoms of distress into categories of psychopathology can medicalise everyday problems.6 In recent years the network approach has offered an alternative way of thinking about mental health problems.8 This approach conceptualises psychopathology as a dynamic system of causally related symptoms; it is not the mental disorder that provokes the symptoms, but symptoms that provoke or reinforce other symptoms. Several studies have applied the network approach to examine the nature of mental health problems in large epidemiological databases and longitudinal data of …

Mental health problems among 4–17-year-olds with hearing problems: results from a nationally representative study

Objective: This study aimed to characterize the risk of mental health problems among a representative sample of 6,310 4–17-year-olds, 147 of whom had parent-reported hearing problems.Methods: The study used data from the Young Minds Matter survey. The Diagnostic Interview Schedule for Children (DISC-IV) assessed prevalence of mood, anxiety and behavioural disorders. The Strengths and Difficulties Questionnaire (SDQ) assessed social and emotional problems. Logistic regression models were used to estimate odds of having mental health problems adjusting for child factors (speech and language problems, global health, age and gender), family factors (family structure, parent income, education, financial strain and psychological distress) and school-related factors (bullying, school liking, school absence).Results: In unadjusted analyses, children and young people with hearing problems had substantially higher odds of most mental health problems. Hearing problems were not associated with any mental health problem among 4–11-year-olds after adjusting for other child factors. After adjustments for child, family and school-related factors, 12–17-year-olds with a hearing problem remained at greater risk of social phobia and generalized anxiety (DISC-IV), and of peer and emotional problems (SDQ).Conclusions: Clinicians caring for children and young people with hearing problems should be alert for heightened risk of specific mental health problems based on age and the nature of hearing problems. Understanding a wider range of correlates associated with the higher prevalence of mental health problems may allow health professionals to be more informed about the nature of mental health problems that are comorbid to hearing problems.

Epidemiological Profile of Depression and Anxiety in a City of the South of Minas Gerais

The goal of this study was to verify the prevalence of patients with mental disorders treated in hospitals and health centres of Itajuba (MG). An observational, descriptive, cross-sectional and retrospective study was carried out, analysing medical records through descriptive statistics. It was estimated prevalence of 25% and less expected of 22%, confidence level was 95% and power of 80%, with a sample of 1298 people. The BioEstat 5.0 program was used for chi-squared statistical tests with bivariate data analysis. In the result, the association between the prevalence of mental disorders was 27.6% for depression and 46.6% for anxiety. There was a prominence of depression among women aged 40 to 49 years and over 60 years and an important evidence of anxiety in women aged 40 to 49 years and 20 to 29 years; Almost 1.5 times higher in the development of anxiety in detriment of depression. Therefore, the data corroborate the multifactorial nature of mental health problems, aiming the improvements of actions related to the patients’ quality of life, identifying the factors associated with the mental disorders, and raising the awareness of the health team and the population about the importance of this theme.

College Students: Mental Health Problems and Treatment Considerations.

Attending college can be a stressful time for many students. In addition to coping with academic pressure, some students have to deal with the stressful tasks of separation and individuation from their family of origin while some may have to attend to numerous work and family responsibilities. In this context, many college students experience the first onset of mental health and substance use problems or an exacerbation of their symptoms. Given the uniqueness of college students, there is a need to outline critical issues to consider when working with this population. In this commentary, first, the prevalence of psychiatric and substance use problems in college students and the significance of assessing age of onset of current psychopathology are described. Then, the concerning persistent nature of mental health problems among college students and its implications are summarized. Finally, important aspects of treatment to consider when treating college students with mental health problems are outlined, such as the importance of including parents in the treatment, communicating with other providers, and employing of technology to increase adherence. It is concluded that, by becoming familiar with the unique problems characteristic of the developmental stage and environment college students are in, practitioners will be able to better serve them.

Treating the cause, not the symptoms, of mental illness stigma

People with mental illness are frequently faced with stigmatising attitudes that make daily life a struggle. Often, these attitudes are a result of misinformation about the nature of mental health problems, including beliefs such as that people with mental disorders are violent, incompetent, and to be blamed for their illness.1 More often than not, people with mental illness begin to internalise these beliefs, which can lead to decreased self-esteem, quality of life, and social withdrawal.2 Unfortunately, attempts to design interventions aimed at reducing the internalisation of stigma have proven largely unsuccessful.

A Lifetime of Trauma: Mental Health Challenges for Higher Education in a Conflict Environment in Afghanistan

More than 30 years of war in Afghanistan have resulted in immense policy challenges to address the resulting mental health issues. The purpose of this policy analysis is to examine the potential role of higher education in addressing the pressing mental health problems in Afghanistan’s public universities and higher education institutions as a major policy challenge. We define and spell out the extent and nature of the mental health problems and policy issues involved, putting them in the context of students in a war environment. We discuss efforts by the leadership of the Ministry of Higher Education to respond to the physical damage of war and the resulting mental health crises in a setting of very scarce human and financial resources. We describe a system of higher education battered by years of war yet seeking to rebuild and raise quality even while the fighting continues. The conditions of the higher education system are described, as well as the scope, complexity and nature of mental health problems, and major challenges faced in trying to rebuild both the system and the lives of the higher education community. We spell out the immense challenges faced in rebuilding a system badly devastated by war while dealing with the tremendous human mental health toll experienced by its students, faculty, and staff. We conclude by setting out some possible directions, options and recommendations for responding to the mental health problems while recognizing the difficulties higher education faces in trying to respond to them.

Universities' expectations of pastoral care: Trends, stressors, resource gaps and support needs for teaching staff

Since the mid-90s, the university environment has challenged the motivation of academic staff to engage in pastoral care. A literature review revealed five themes that aligned with analysis of interview data from a previous study (Laws and Fiedler, 2010). The key themes were i) staff were often disturbed by unplanned intrusions of students who exhibited behavioural problems or sought emotional support, ii) the management of emotions in face-to-face encounters was stressful, iii) staff felt under-equipped for dealing with Mental Health (MH) issues, iv) standards and control needed updating and v) counselling and disability services did not meet academics' need to know about 'at risk' students. Having identified the incidence of mental health issues among Australian University students, this study aims to locate literature that describes how well current university policies/protocols are supported by Evidence Based Practice in the management of MH problems in the student population. Findings from a content analysis of the literature were triangulated with verbatim comments recorded during a previous study that utilised semi structured interviews with 34 academics at the School of Nursing and Midwifery and the School of Commerce at the University of South Australia (Laws and Fiedler, 2010). Lack of clarity on role boundaries around promotion of students' well-being was not clearly defined. The Higher Education (HE) institutions' slowness in responding to mental health needs of students combined with the increasing expectations of academics' performance monitoring has lead staff to avoid deep investment in their students' well-being. The literature indicates that students are in need of psychological support, but pastoral care remains ill-defined despite enduring expectations held by university administrators. Teacher motivation is diminished by time spent with students in need of emotional support which is not acknowledged in workloads. Staff stress is increased by 'emotion work' requiring a greater integration of resources that guide them toward more appropriate and timely student support. Staff require ongoing professional development on the nature of MH problems among students. There is a need for specific orientation programs that better define pastoral care and identify support services for staff and students. Universities need to focus on what is needed to create a well-being environment. Workload allocations must include 'emotion work', and mental health professionals must be employed to improve intervention and support not only for students but also for University staff. With better defined pastoral care roles, academics can more effectively balance their intrinsic and extrinsic motivations toward both personal and corporate objectives. Further research into the efficacy of university resourcing of programs and services is needed.

Organisations adjusting to change: A discussion of the impact of an Improving Access to Psychological Therapies (IAPT) service on the organisational dynamics of an existing psychological therapies department

Content and FocusHealth systems are typical examples of what Halton (1995) describes as ‘dependency cultures’. People who chose to work in such cultures are, it is argued, vocationally motivated by a desire to help those in the ‘dependent’ position. The primary value of this culture is to maximise the development, health and welfare of the people who need these services. The introduction of market forces into the National Health Service (NHS) has gradually undermined this value as scarce resources dictate to who and how much service could be given. Re-evaluation and restructuring of therapeutic services is necessary to ensure they are run efficiently and effectively; however, problems arise when lack of recognition or matching of the ‘dependency values’ and the implicit primary task of ‘caring for others’ obstructs the vocational motivation of practitioners. This has the potential to introduce conflict between the values of the different staff groups within and between services leading to confusion and stress. The introduction of Improving Access to Psychological Therapies (IAPT) has been criticised for promoting an idealised culture of ‘cure’ which has failed to acknowledge the real complexity, and often comordidity of mental health problems (Fairfax, 2008). This change of emphasis from ‘care’ to ‘cure’ denigrates both the primary task and the morale of staff whose abilities to care and to act realistically by accepting the often complex and chronic nature of mental health problems, are undermined (Stokes, 1994). Bion’s (1961) concept of unconscious processes within groups and organisations is used to provide a psychodynamic understanding of how the introduction of IAPT into an NHS psychological therapies department created tensions between the non-IAPT and IAPT services, disrupting the organisations ability to work towards its primary task of care. Using the author’s observations and experiences as a trainee counselling psychologist within this service, the paper concludes with a discussion of how counselling psychology’s humanistic values and pluralistic training provides a unique perspective from which to arbitrate professional conflicts, and facilitate adjustment to organisational change.

Organisations adjusting to change: A discussion of the impact of an Improving Access to Psychological Therapies (IAPT) service on the organisational dynamics of an existing psychological therapies department

Content and FocusHealth systems are typical examples of what Halton (1995) describes as ‘dependency cultures’. People who chose to work in such cultures are, it is argued, vocationally motivated by a desire to help those in the ‘dependent’ position. The primary value of this culture is to maximise the development, health and welfare of the people who need these services. The introduction of market forces into the National Health Service (NHS) has gradually undermined this value as scarce resources dictate to who and how much service could be given. Re-evaluation and restructuring of therapeutic services is necessary to ensure they are run efficiently and effectively; however, problems arise when lack of recognition or matching of the ‘dependency values’ and the implicit primary task of ‘caring for others’ obstructs the vocational motivation of practitioners. This has the potential to introduce conflict between the values of the different staff groups within and between services leading to confusion and stress. The introduction of Improving Access to Psychological Therapies (IAPT) has been criticised for promoting an idealised culture of ‘cure’ which has failed to acknowledge the real complexity, and often comordidity of mental health problems (Fairfax, 2008). This change of emphasis from ‘care’ to ‘cure’ denigrates both the primary task and the morale of staff whose abilities to care and to act realistically by accepting the often complex and chronic nature of mental health problems, are undermined (Stokes, 1994). Bion’s (1961) concept of unconscious processes within groups and organisations is used to provide a psychodynamic understanding of how the introduction of IAPT into an NHS psychological therapies department created tensions between the non-IAPT and IAPT services, disrupting the organisations ability to work towards its primary task of care. Using the author’s observations and experiences as a trainee counselling psychologist within this service, the paper concludes with a discussion of how counselling psychology’s humanistic values and pluralistic training provides a unique perspective from which to arbitrate professional conflicts, and facilitate adjustment to organisational change.

Comparison of the Prevalence of Mental Health Problems in Deaf and Hearing Children and Adolescents in Australia

The aims of the present study were to (i) identify the prevalence rate and nature of mental health problems in a group of Australian deaf children and adolescents and compare these to those reported for the Australian hearing population; and (ii) identify specific demographic characteristics that may typify deaf children and adolescents with mental health problems. Sixty-six parents of deaf children and adolescents aged 6-18 years, their teachers and 38 adolescents participated in the study. Data related to mental health problems were collected using the Child Behaviour Checklist and Youth Self-Report. Data related to demographic characteristics were obtained via parent and teacher surveys. The overall prevalence rate of mental health problems reported by parents and adolescents in the present study is comparable to that of the Australian hearing population. Parents in the present study, however, reported significantly more concerns on the social problem and thought problem scales than did Australian parents of hearing children and adolescents. There were also significant differences between the prevalence and nature of mental health problems as reported by the deaf adolescents in the present study when compared to deaf adolescents in another Australian study. These differences appear to be explained by differences in the preferred communication mode of the participants in the two studies. The known heterogeneity within the Australian deaf child and adolescent population with respect to preferred mode of communication has important implications not only for the appropriate selection and use of psychiatric instruments in assessing child and adolescent mental health but also for the accurate reporting of the prevalence and nature of mental health problems within this population.

A mix-method approach to the cultural understanding of distress and the non-use of mental health services

Background: The rationale for conducting mixed-method studies is usually based on the desire to combine the complementary strengths of qualitative and quantitative research. Typically, the former provides in-depth descriptions offering strong internal validity while the latter provides strong external validity. The exclusive use of quantitative methods in mental health research presents certain limitations which lie in the subjective nature of mental health problems and related behaviors, and the fact that these are mediated by cultural context.Aims and methods: This paper illustrates, along with the Pathway and Barriers to Mental Health project, the usefulness of using a mixed-method design to study mental health problems and related behaviors in a culturally diverse community.Results: The results show how the various quantitative and qualitative stages of the project were implemented in a Sequential Transformative Design that allows for a better identification and understanding of community mental health problems. This type of mixed design contributed to the development and evaluation of a regional cultural consultation service in mental health.Conclusion: A mixed-methods approach does not simply make positivist science stronger; rather, it contributes to do better research and tailored intervention.

SOME IMPLICATIONS OF THE CHILDREN'S NATIONAL SERVICE FRAMEWORK FOR SOCIAL WORK PRACTICE WITH REGARD TO CHILD MENTAL HEALTH

This paper discusses the implications of the recommendations of the Children's National Service Framework for children and young people with mental health problems, and considers the interface with social work practice. Children's mental health has never previously attracted so much attention from government departments. This is seen as a reflection of the recent recognition of the widespread nature of mental health problems in the community and an understanding of the cost to society if they are left unaddressed.