● Round-table Conference (RTC)
○ RTC 운영결과
“우울증, 자살 그리고 한국사회 Round-table Conference”의 청소년 분야는 2010년 12월 10일(금), 성인 분야는 2010년 12월 17일(금), 노인분야는 2011년 1월 22일(토)에 각각 개최하였으며 각 행사에는 관련 임상전문가, 의학전문기자 등이 참석하여 토론을 함께 하였다.
청소년, 성인 분야는 우울증과 자살에 대한 문제점과 사회적 편견 극복방안의 주제로 진행되었으며, 노인 분야는 노인 우울증 및 자살 관리 지침 개발을 위한 근거 구축 전략의 주제로 진행하였다.
○ 토의내용
(1) 역학
가. 우울증
현재 5년 간격으로 수행하고 있는 정신건강실태조사를 2-3년으로 바꿀 필요가 있다. 잦은 간격으로 실태조사를 시행하게 되면 정확한 현황파악으로 효과적인 정책결정을 위한 올바른 정보제공을 제공할 수 있을 것이다.
청소년 우울증은 주요 질환인 주의력결핍과잉행동장애 유병률인 4.5%에 비해 높아 우울증의 심각성이 우려된다. 노인 우울증은 무의욕, 집중력저하, 인지기능저하 등의 증세가 매우 흔하게 보여 일반 성인과 동일한 진단기준으로 노인 우울증 유병률을 조사하게 되면 유병률이 낮게 나온다. 따라서 노인 우울증을 감별진단 할 수 있는 진단기준 마련이 필요하다.
나. 자살
자살은 자살생각, 자살기도, 자살의 단계로 이루어지는데 현재 국내 자살관련 역학자료는 경찰청과 통계청 자료로 자살 사망자에 대한 자료이다. 각 단계 역학자료는 통계청에서 일부 청소년 대상으로 연구한 자료가 있으나 성인, 노인에 대한 자료는 거의 없는 실정이다. 자살 예방을 위해 단계별 개입방법이 다르고 효율적인 관리를 위해서는 단계별 역학연구가 필요하다.
(2) 우울증, 자살에 대한 사회적 편견 감소와 올바른 정보제공을 위한 사회적 노력 필요
일반적으로 많은 사람들은 정신과 질환 및 약에 대해 많은 편견을 가지고 있다. 정신과 질환은 자신의 정신적 나약성과 결부하거나 미친 사람 등으로 생각하는 경우가 많으며, 정신과약은 평생 복용해야 되며, 정신 이상자들이 먹는 약 등의 편견을 가지고 있어 정신과약에 대한 거부감이 외국에 비해 많다. 그리고 언론에서 조장하는 정신과 약에 대한 선입견, 편견 등도 있어 이를 개선하기 위해서는 정신과 질환, 약에 대해서 인터넷 등에 난무하는 잘 못된 정보가 아닌 일반인들이 이해하기 쉬운 올바른 정보제공이 필요하다. 이러한 정보제공을 위해서는 정부, 언론, 관련 전문가, 관련 단체 등의 세심한 노력이 필요할 것이다.
(3) 자살 관련 요인 파악
가. 위험요인
자살의 위험요인 중 지속적 유발요인은 우울증, 어린 시절 경험 등이 있다. 국내연구에 의하면 어린 시절 부모의 무관심, 폭력 등 상처 등이 있다. 특히 우리나라에서는 육아를 대부분 담당하는 어머니가 육아스트레스 등으로 우울증에 걸리게 되면 어머니와 아기의 애착형성 미약, 발달 지연, 아기를 학대하는 경우가 많으며, 우울증을 가진 어머니에게서 태어난 어린이는 자살률이 더 높다는 보고도 있다. 그리고 요즘 인터넷의 발달로 인해 자살사이트 등을 통해 동반 자살하는 경우가 많아졌으며, 경제불황이 계속되면서 생활고를 비관해 자살하는 이른바 ‘생계형 자살’이 늘어나 사회적 문제로 대두되고 있다.
나. 보호요인
보호요인들에는 가정의 화목, 원만한 인간관계, 안정된 직업, 취미, 종교, 규칙적인 생활, 운동, 수면 등이 있는데 이러한 보호요인을 강화시켜주는 지지체계가 필요하다. 자살 직전의 청소년은 고립감, 외로움, 절망 등이 있는데 이러한 청소년에게 희망을 가질 수 있도록 가족뿐만 아니라 교사, 친구, 지역사회 지지단체 등이 도와주어 보호요인을 갖게 하는 등 사회적인 접근이 중요하다.
(4) 자살 예방을 위한 국가 차원의 개입 필요
일본, 호주, 미국, 핀란드 등 외국에서는 자살 예방을 위해 범국가적 차원에서 노력을 하고 있어 우리나라에서도 자살률을 줄이기 위해 국가적 차원에서 적극적인 노력을 기울일 필요가 있다.
가. 효율적인 자살예방프로그램 활성화
나. 자살예방대책을 위한 제도적, 법적 측면 보완 필요
다. 심리학적 부검의 필요성
라. 생명존중에 대한 사회적 가치 정립 필요
(5) 기타 연령대별 논의사항
가. 청소년
- 원활한 의뢰와 연계 시스템의 필요성
- 정부 부처 간의 원활한 업무 연계가 필요
나. 노인
- 기타 우울증의 조기치료 필요
- 임상진료지침의 적절한 목표사용자 선정 중요성
- 근거마련을 위해 필요한 연구
● 고찰
청소년, 성인, 노인의 우울증과 자살에 대해 관련 전문가들이 모여 각 연령대만 집중하여 문제점과 대책 등에 대해 전문적이고 심도깊게 논의하여 전문가 의견을 한 곳에 모아 올바른 정보를 제공과 대책을 마련할 수 있는 발판을 마련했다는 점에 의의가 있다. 비공개로 진행된 RTC는 논의 내용을 일반인, 사회에 이해하기 쉽게 알려주며 그들의 인식을 변화할 수 있는 확산 방안 마련에 대한 심도있는 논의가 부족하였으며, 논의된 내용도 바로 정책화 되지 못한다는 한계점이 있다. 우울증과 자살기도자들은 다른 질환과 달리 치료율이 낮아 재발, 자살 등의 문제를 초래할 수 있어 지속적인 치료의 장애요인에 대해 경제적, 사회적, 환경적 요인을 파악하고 이를 감소할 수 있는 방안을 모색하는 연구와 우울증과 자살에 대한 사회적 편견의 효과적인 해소 방안을 마련하기 위해 다학제적 접근을 통한 연구가 필요하다. 국내의 근거 마련을 위해 현재 알고 있는 근거, 모르고 있는 근거, 불확실한 근거에 대해 정리가 필요하다.
● 결론 및 정책제언
청소년 우울증은 주의력결핍과잉행동장애 유병률 4.5%에 비해 더 높은 것으로 나타나 심각성이 우려되며, 노인 우울증 증상은 성인과 달라 성인과 동일한 진단기준으로 조사하게 되면 과소 추계 될 위험이 있어 노인 우울증을 감별진단 할 수 있는 진단기준 마련이 필요하다. 자살의 경우 위험요인과 보호요인이 있는데 위험요인이 증가했을 때는 보호요인들을 증가시켜 자살에 이르지 않도록 하는 사회적 노력이 필요하다.
현재 5년 간격으로 수행하고 있는 정신건강실태조사를 2-3년 간격으로 실태조사를 시행할 수 있도록 정책적 변화가 필요하며, 자살 직전의 사람들에게 희망을 가질 수 있도록 사회적 지지체계를 강화시킬 수 있는 정책 마련이 필요할 것이다. 생명존중에 대한 사회적 가치 정립을 위해 우선적으로 학교에서의 지속적인 생명존중 교육을 할 수 있도록 하며, 자살에 대한 편견이 심한 우리나라에서 자살원인을 파악하기 위한 심리적 부검을 활성화위해 우리나라의 문화적 특성을 반영하여 변형된 방법을 강구할 필요가 있으며 관련 정부기관, 경찰 등의 관련기관의 협조와 예산과 전문가 양성을 위한 정책적 지원방안을 마련해야 할 것이다.
1. Background
According to the Epidemiological Survey of Psychiatric Illnesses in Korea (2006), the lifetime prevalence of depression increased from 4.0% to 5.6% in 2011, while that of other psychiatric illnesses decreased. In terms of gender, the annual prevalence of depression in females (3.2%) was twice as high as that in males (1.7%). The 2009 Causes of DeathStatistics (Statistics Korea) reported that the number of deaths caused by suicide was 15,413, and the suicide rate was 31.0 per 100,000, an
increase of 19.3% from the previous year. In particular, the suicide rate for those over 80 was over five times higher than the rate for those in their twenties. Moreover, suicide was ranked as the number one cause of death among individuals aged between 10 and 39 and the number two cause among those aged between 40 and 59.
In response to the recent emergence of depression and suicide as a huge social issue, this report aims to seek countermeasures by gender and age group, thereby minimizing social prejudices toward depression and suicide.
2. Method
A closed meeting between clinical professionals and a limited number of adolescents, adults, and elderly people of each age group was conducted with the purpose of finding solutions to the problems of and reducing social prejudices toward depression and suicide issues.
The RTC (round-table conference) was composed of a presentation part, in which each speaker gave a 10- to 15-minute presentation, and a discussion part, in which the panel members discussed the presentations.
3. Round-Table Conference (RTC)
1) Results of the RTC
The Round-Table Conference on Depression, Suicide, and Korean Society was divided into adolescent, adult, and elderly sectors and held on Friday, December 10, 2010, Friday, December 17, 2010, and Saturday, January 22, 2011, respectively. Clinical professionals and medical reporters participated in the discussions with each group. While the adolescent and adult sectors focused on measures to solve the
problems of and overcome social prejudices toward depression and suicide, the elderly sector was aimed at establishing evidence for developing guidelines for elderly depression and suicide management.
2) Presentation Content
(1) Adolescent
a. Internal and External Research Trends in Adolescent Depression and Suicide Prevention Efforts
According to a survey of the prevalence of psychiatric illnesses in children and adolescents in Seoul (2005), interviews with the parents of the subjects revealed about a 2% prevalence of depression-related illnesses, whereas self-reports by the subjects showed a 7.37% prevalence. Moreover, examinations of relevant studies conducted both internally and externally have demonstrated the necessity for further studies regarding suicide risk and prevention factors and have revealed the inadequacy of integrated data by institution and region on the present status of adolescent suicide, which indicates a need for cooperation among various institutions that deal with adolescent mental health.
b. Factors and Present Condition of Adolescent Suicide
In order to prevent the rapidly increasing adolescent suicide rate, a social atmosphere that minimizes prejudice toward psychiatric illnesses should be created through wide-ranging public efforts by the press, the educational arena, mental health experts, and other relevant organizations, along with campaigns to increase public awareness. Furthermore, supportive environments should be established that are
based on that type of social atmosphere so that depressed or suicidal adolescents can actively engage in psychiatric treatment.
c. Online Game Addiction and Suicide
According to recent research on certain adolescents who have been diagnosed with high-level or latent Internet addiction, 31.3% had attention deficit hyperactivity disorder (ADHD), 28.7% had depressive disorders. Among those classified as latent addicts, 43.2% had ADHD and 40.5% had a depressive disorder. On the other hand, among those diagnosed as high-risk addicts, 50% had other mood disorders such as
dysthymic disorder and biopolar disorder and 40% had ADHD. Internet addiction treatments include cognitive behavior therapy (CBT), medication, and motivational enhancement therapy (MET).
d. School Mental Health Promotion Service : Development and Use of a Screening Scale
There need to be efforts to decrease social prejudices toward students with psychiatric illnesses, as well as nationwide educational campaigns to improve awareness of the importance of the mental health of adolescent students. There is also a need for relevant governmental departments such as the Ministry of Education, Science and Technology and the Ministry of Health and Welfare to share their roles and secure a budget for recruiting appropriate personnel to be responsible for mental health examination. In addition, a systematic student mental health examination
program is required, in which the process of the second examination is unified and the referral system in the third examination and subsequent treatment is established.
e. School Mental Health Promotion Service
To prevent adolescent suicide, a mental health promotion program should be aimed at dealing with the mental health issues of students and their parents, such as depression, anxiety, and stress, as well as other social issues, including personal relationships. In addition, in order for mental health services in the schools to be more effective, practical measures such as specialization of screening scales and referral systems are needed.
f. Eradication of Social Stigma and Future Research Direction
There are various strategies for eradicating social stigma toward mental illnesses. In England, for example, relevant institutions and organizations conduct efforts in 28 regions nationwide in cooperation with one another under the slogan “Time to Change.” Their public awareness promotion efforts also include Education Not Discrimination-Rethinking Mental Health (END) programs. Similarly, in Korea, the Central Mental Health Supporting Committee holds discussions with relevant institutions and organizations and presents workshops conducted by individuals engaged in mental health service in local communities. The committee also runs a slogan contest and distributes promotional materials. Future studies of adolescent suicide need to focus on understanding the present situation through statistical analysis of relevant data. Furthermore, therapeutic methods that include both medication and non-medication should be studied, focusing on high-risk groups.
2) Adult
a. Causes of Depression and Suicide
One of the uncontroversial facts about suicide is that patients with suicidal intentions eventually follow through in some way. It is very hard to stop patients with strong intentions from killing themselves, even with the application of restraints, careful observation, or clinical technology. Goldstein et al. (1991) examined risk factors in 1,906 patients by multiple regression analysis and suggested a statistical model for suicide prediction. This model, however, never succeeded in detecting in advance
a single patient who eventually committed suicide. Again, not all suicides can be prevented, so those responsible for providing treatment should not be blamed for not being able to predict their patients’ suicides.
b. Epidemiologic Studies of Depression and Suicide
In Korea, the lifetime prevalence of main depressive disorders is 5.6% (3.6% in males and 7.6% in females), and the annual prevalence is 2.5% (1.7% in males and 3.2% in females). The annual prevalence in 2006, for example, increased from 1.8% to 2.5% compared to 2001. The prevalence of mood disorders in Korea is rather lower than in Western countries and similar to Japan and China, but its threshold value is much higher than in the US. In addition, 3.2% of the population between the
ages of 18 and 65 in Korea has made a suicide attempt, which is a very high rate compared to many other countries. These facts indicate that suicide attempters who visit emergency rooms are not managed properly in terms of psychiatric diagnosis and treatment, even when they show high rates of mood disorders and intend to commit suicide in the near future. There is an urgent need for measures to prevent suicide
attempters from ultimately committing suicide by providing them with appropriate psychiatric treatments through health policies, as the US and Japan do.
c. Suicide and Crisis Intervention
To prevent suicide, suicidal thoughts should be measured first. They are usually measured by directly asking suicidal patients the following questions, by stages: if they feel suicidal, if they think about suicide, if they think about suicidal methods in detail.
In addition, suicidal people should reduce risk factors while increasing protection factors, which include optimistic views of life, harmonious family and personal relationships and smooth communication with them, active attitudes toward things, stable occupations, pastimes, and religion.
d. Ways to Overcome Social Stigma toward Depression
To reduce depression and suicide rates, adequate and practical information about psychiatric illnesses and treatments should be provided. Then, institutional improvements should be made in order to abolish social discrimination toward mental illness, thereby promoting a better perception of psychiatric disorders and treatments.
3) Elder
a. Elderly Depression and Necessary Grounds for Suicide Intervention
From the epidemiologic perspective, accurate epidemiologic examinations require detailed group analysis and practical interpretation of secondary data. From the diagnostic perspective, there is a need for evidence for the determination of effective tools for large-scale screening and for the importance of non-depression-related factors, such as physical illnesses, in depression prognoses. From the therapeutic
perspective, there is a need for evidence for the preventive effects of medication and its effect on compliance rates of antidepressants. From the preventive perspective, there is a necessity for primary and secondary prevention. The evidence for elderly suicide intervention should include an analysis of changes in elderly suicide and evidence for the determination and prevention of risk factors for suicide.
b. Depression and Suicide of Korean Elderly People: Epidemiologic Evidence
The prevalence of depression in elderly Koreans is 17.9% in terms of dimensional classification and 27.8% in terms of categorical classification. In addition, it has been discovered that even minor depressive disorders affect the quality of life and perceptions of patients. Risk factors for depressive disorders are: low-level educational background, illiteracy, low income, declining cognitive function, dementia, and stroke, regardless of gender and age. Because the elderly suicide rate was 4.6%, there has
proven to be a close relationship between suicide and depressive disorders, but systematic epidemiologic studies of suicide are lacking.
c. The Level of Evidence for Clinical Tests to Treat Depression in Korea
Clinical tests aimed at Korean people have been extremely lacking, and suitable journals for publication of clinical studies on depression in Korea should be searched. Furthermore, improvement patterns of depression symptoms, such as insomnia and other physical signs, should be examined through analysis of the characteristics of common symptoms among the Korean population. In addition, there is a need for evidence for clinical tests to evaluate improvements of depression symptoms in
patients with physical illnesses.
d. Strategies to Build Evidence for Developing Guidelines on Management of Elderly Depression and Suicide
To supplement insufficient evidence, the possibility of establishing evidence should be examined through analysis of existing clinical guidelines and consultation with experts. The existing guidelines should be determined by their targets and perspectives whether they are aimed at psychiatrists, non-psychiatric doctors, or non-doctor medical professionals; whether they come from a diagnostic or therapeutic perspective; and whether they deal with overall depression or specific types of depression. To supplement insufficient evidence, evidence should be created through add-on, independent, extension, and integration studies.
3) Discussion Content
(1) Epidemiology
a. Depression
Current 5-year interval between the Epidemiological Survey of Psychiatric Illnesses, there is a need to replace with a 2-3 years. Survey conducted at frequent intervals to determine if the correct status for effective policy-decisions will be able to provide the correct information.
Significant symptoms of depression among young adults include changes in sleep patterns and fatigue. For this reason, if the same diagnostic criteria used for adults are applied to measure the prevalence of elderly depression, it appears to be lower than it actually is. Thus, separate diagnostic criteria for elderly depression should be established.
b. Suicide
The process of suicide is composed of three stages: suicidal ideation, suicide attempts, and commitment. However, the current epidemiologic data regarding suicide in Korea, provided by the National Police and the Statistics Korea, focuses only on deaths by suicide. The Statistics Korea data partially handles each stage of suicide in adolescents, but does not deal with adult and elderly suicide with the same approach. As suicide intervention varies depending on the stage, epidemiologic studies of each
stage are needed.
(2) The Necessity of social efforts for reducing stigma and provision of correct information about depression and suicide
Many people have stigma against psychiatric medicines; they tend to believe that such medicines are for insane people only and have to be taken for the rest of one’s life, and that they are the only way to cure mental illnesses. Moreover, hostility toward psychiatric medication in Korea is higher than in many other countries. These stigma and hostility are mostly due to incorrect information. Therefore, clinical experts and
relevant institutions and organizations should make efforts to provide the public with correct information about psychiatric medication.
(3) Suicide factors
a. Risk factors
Continuous risk factors for suicide include depression and traumatic childhood experiences. According to a domestic study of suicide attempters, parents’ indifference, violence lead to changes in children’s value systems and a distorted way of thinking. In Korea, mothers are responsible for the majority of child care in most homes. Some studies have reported that mothers with depression are likely to abuse
their children, who are in turn apt to become emotionally unstable and have low self-esteem, negatively affecting their socialization. Studies further suggest that children whose mothers suffer from depression are likely to commit suicide. In recent Internet events, there have been numerous cases in which people commit suicide
together though online suicide communities. Moreover, along with continuous economic depression, so-called “livelihood suicide,” which is committed due to hardships in life, is emerging as a social issue.
b. Protective factors
While there are suicide-causing factors, there are protective factors as well, which include a harmonious family, smooth personal relationships, a secure job, pastimes, religion, regular routine, exercise, and sleep. There should be a support system and efforts to strengthen such protective factors when risk factors increase.
(4) For suicide prevention requires the nationwide intervention
Japan, Australia, USA, Finland, etc. in foreign countries for suicide prevention efforts at the national level, and pan it to reduce the suicide rate in Korea, an active effort at the national level is necessary.
a. Vitalization of Effective Suicide Prevention Programs
Many studies have indicated the effectiveness of “gatekeeper” training for the prevention of suicide and the importance of teachers’ roles as gate keepers.
Most adolescents talk about their problems to their friends; therefore, a peer support program can help friends to build networks when there are signs of dangerous psychological states. Similarly, a system that can help people surrounding such adolescents in need to refer them to experts should be vitalized in order to prevent suicide.
b. The Necessity of Institutional, Legal Improvements for Suicide Prevention
How a suicide attempt to suicide prevention needs to block. Methods belong to the top of the suicide warning labels on pesticides with the rural, etc. Keep away easily to hand, including measures designed to manage the institutional aspects are needed.
c. The Necessity of Psychological Autopsy
Understanding the causes of suicide is crucial in preventing suicide, and conducting psychological autopsies is one way to do this. Other accumulated data used as input for the prevention of suicide and death, all the major psychological and social stress experienced by the deceased, personality characteristics and psychological behaviors, and psychiatric diagnosis before death and the situation is assessed. To activate it, reflecting the culture of the country how to transform the
psychological autopsy is necessary. In the case of the suicide case, the police investigation was done at the police report, along with information about the psychological autopsy study to determine the cause of suicide, if you will help a lot.
d. Social values need to establish respect for life
The Korea society's fast economic growth, urbanization, human respect, nuclear family, personalization is ever about the importance of life, home and in school education is becoming increasingly violent and sexually-oriented school education and youth games are rife, life is a slight wave and social value, and I'm getting encouraging suicide, confusion prevails and establishment of social value for respect life, it is necessary to be done.
(5) Others
a. Adolescent
- The Necessity of a Smooth Referral System
There are many adolescents who cannot receive early detection of and proper treatment for depression because of ignorance and prejudice on the part of teachers and parents. Therefore, there is a need for educating teachers and parents, as well as a smooth referral system that can lead to early effective treatment for adolescents in need. Youth counselors should also be trained to determine whether a student needs a referral to receive professional treatment.
- The Necessity of Coordination between Governmental Offices
Because various ministries, including the Ministry of Gender Equality and Family; Ministry of Education, Science and Technology; and Ministry of Health and Welfare are responsible for adolescent depression and suicide, consistent and systematic operation of relevant policies through coordination among them is required.
b. Elder
- The Necessity for early treatment of Elderly Depression
Among elderly patients with depression, sub-clinical patients are hard to diagnose based on physical illnesses or other common symptoms for elderly people likely to commit suicide. Therefore, even minor depressive disorders should be diagnosed early and treated.
- The Importance of Determining Target Users of Clinical Guidelines Unlike many other countries, depression in Korea is dealt with in psychiatric clinics, while sub-clinical depression is treated by internal medicine or general practitioners or Alzheimer’s centers. Therefore, guidelines for these non-psychiatric professionals should be
established so that they can play their roles as gatekeepers. A majority of suicide attempters are medical aid beneficiaries, so they prefer mental health centers to psychiatric clinics for financial reasons. Thus, guidelines for mental health center personnel or home-visiting personnel are also needed.
- Research Required to Develope Evidence
Studies should be conducted that focus on determining distinguishing characteristics of elderly depression and high-risk groups and understanding the current condition, including the relationship between suicide and social issues, such as solitary lifestyles of the elderly. To establish evidence, it should be classified into evidence we know of, evidence we do not know of, and uncertain evidence. For this, professionals first review and integrate previous studies.
4. Discussion
Adolescents, adults, elderly depression and suicide, experts gathered for each age-related problems and how to protect Taiwan by focusing in-depth discussion about the professional and the expert opinion provided the correct information in one place and measures that can arrange scaffolding has established that there is significant. RTC conducted in closed meeting with the public, easy to understand society tells you that you can change their perception of the spread of established measures was the lack of an in-depth discussion, nonuindoen jeongchaekhwa content that would not just have limitations. Depression and suicide, prayers, unlike other diseases and cure rate, low recurrence, and suicide can lead to problems such as barriers to continued treatment for the economic, social and environmental factors that can identify and looking for ways to reduce the research and about depression and
suicide, ways to eliminate social prejudice and effective multi-disciplinary approach in order to lay over the research is needed.
5. Conclusion
Adolescent depression prevalence of ADHD appears to be higher than 4.5% are concerned about the severity, depressive symptoms, elderly and dependent adults and adults with the same diagnostic criteria when the polls run the risk of underestimated to the differential diagnosis of elderly depression the preparation of the diagnostic criteria are needed. Current 5-year interval between the mental health survey for 2-3 year intervals so that they can enforce the policy changes needed to survey and hope to the people on the verge of suicide, to ensure that we have to strengthen the social support system, it will be necessary to raise the policy. Respect life and social value for the first formulation can respect life at school, and serious stigma to suicide in South Korea to determine the cause of suicide, psychological autopsies to enable the country to reflect the cultural characteristics of variations need to seek ways and
the relevant government authorities, police agencies, including the budget and professional development assistance and policy support measures will need to prepare for the will.
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