13Toward an Improved Approach to Prevention

Publication Details

The preceding chapters described the substantial scientific progress in the conceptualization, design, assessment, and evaluation of preventive intervention approaches for children, youth, and families since the 1994 Institute of Medicine (IOM) report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. There has been laudable progress in the science of mental health promotion and prevention of mental, emotional, and behavioral (MEB) disorders. It is now evident that the incidence of some of these disorders, such as depression, can be significantly reduced. There is also evidence to support multiple approaches aimed at strengthening individual, family, and community competencies that have been causally linked to mental, emotional, and behavioral health, either by reducing malleable risk factors for disorders or enhancing protective factors. We call on the nation to put this knowledge into practice. At the same time, as discussed in earlier chapters, we have identified significant gaps in current knowledge and key areas in which more research and infrastructure changes are needed to fully release the potential to significantly reduce MEB disorders among young people.

The promise of preventing MEB disorders, evident in the research over the past several decades, has prompted numerous federal agencies and stakeholder organizations to encourage grantees and community organizations to adopt evidence-based interventions. The National Institutes of Health (NIH) and other agencies have funded multiple parallel research projects. It is now time for a coordinated, strategic approach that brings together the range of resources, provides consistent advice to communities, and strategically aligns research priorities to needs. As discussed in the preceding chapter, although there are a number of interagency efforts, they tend to be focused on a single program or an isolated issue related to prevention rather than on a holistic vision. Historically, prevention has received far less attention than treatment in either mental health or physical health. A fundamental paradigm shift needs to occur. The substantial progress in prevention science summarized in this report calls for the adoption of a prevention perspective and a resolve to test and determine the most promising application of specific evidence-based preventive approaches.

Recommendation 13-1: The federal government should make the healthy mental, emotional, and behavioral development of young people a national priority, establish public goals for the prevention of specific MEB disorders and for the promotion of healthy development among young people, and provide needed research and service resources to achieve these aims.

Accomplishing this will require a more systematic approach at multiple levels—national, state, and local—and continued progress in prevention research.


The 1994 IOM report strongly recommended the creation of a mechanism to coordinate research and services across federal departments, suggesting the creation of a national scientific council as one model, possibly under an office in the White House. A variety of national-level groups (New Freedom Commission on Mental Health, 2003; U.S. Public Health Service, 2000) have concurred in saying that the nation should consider a strong, broad-based public health infrastructure to both monitor and deploy resources in mental and physical health care.

Current federal policy, research, and practice relevant to prevention of MEB disorders are fragmented across a wide variety of agencies. Research on prevention (and treatment) is organized to address individual disorders and problems. However, evidence that common risk factors lead to multiple interrelated disorders and problems, coupled with significant evidence on possible approaches to mitigating these factors, calls for a concerted strategic, national effort to coordinate research, policy, and practice aimed at preventing MEB disorders and promoting healthy development. This effort would build on the significant evidence currently available and continue to be informed by new research as it emerges.

Recommendation 13-2: The White House should create an ongoing mechanism involving federal agencies, stakeholders (including professional associations), and key researchers to develop and implement a strategic approach to the promotion of mental, emotional, and behavioral coordinating and health and the prevention of MEB disorders and related problem behaviors in young people. The U.S. Departments of Health and Human Services, Education, and Justice should be accountable for coordinating and aligning their resources, programs, and initiatives with this strategic approach and for encouraging their state and local counterparts to do the same.

One of the first tasks would be to establish specific, measurable goals for the next 10 years (see Recommendation 13-1) and a strategy to support the accomplishment of goals. In establishing goals, consideration should be given to the prevalence of disorders, costs associated with those disorders, and the strength of the evidence that the disorder is preventable. Promising areas include the prevention of depression, substance abuse, and conduct disorder. Existing surveys provide data on substance use and adolescent (ages 12–17) depression. The Federal Interagency Forum on Child and Family Statistics has recently added an indicator related to the prevalence of depression among youth in its Key National Indicators of Well-Being report and includes indicators of alcohol and drug use. The forum has also identified the need for measures of positive behaviors.1 This could serve as a starting point. Similarly, consideration should be given to the approaches that both promote healthy development and have the greatest potential to affect multiple disorders, such as those aimed at strengthening families.

In developing the strategy, priority should be placed on educating the public on the potential to improve support of the nation’s young people, including efforts to reduce the stigma associated with mental, emotional, and behavioral problems, and on engaging relevant professional and intergovernmental organizations in a coordinated approach to improving support systems for young people and their families. Development of the strategy would have multiple components:

  • Identify and evaluate all federal programs and policies to determine which ones should be recommended to states and communities based on an agreed standard of evidence; these programs should be given highest priority for dissemination.
  • Create networks of prevention delivery programs involving schools, primary health care, behavioral health care, and other community-based programs that are sites for investigation and innovation for both family-centered preventive intervention and individual-centered intervention.
  • Explore the possibility of set-asides or targeted funding for promotion and prevention activities, similar to the set-aside proposed for the Mental Health Services Block Grant (see Recommendation 12-1).
  • Consult with leading researchers, major stakeholder and professional organizations, and constituency groups in developing priorities, goals, and a shared action agenda.
  • Coordinate with relevant foundations to identify priority partnerships aimed at better understanding the implementation of evidence-based programs, possibly through the Child Mental Health Foundations and Agencies network, a collaborative of public and private agencies and foundations interested in issues of child development and public policy.
  • Coordinate with NIH on the development of a 10-year research agenda (see Recommendation 13-5) and plan, organize, and support further research, led by NIH:
    • — To further examine the impact of programs and policies to determine the extent to which they prevent the development of problems, promote mental health, or both. That research should assess the impact of interventions on multiple disorders and problems.
    • — To experimentally evaluate strategies for getting effective programs and policies widely and effectively adopted.
  • Oversee development of approaches to monitor the prevalence of disorders and key risk and protective factors, as well as relevant service use across a range of delivery systems (see Recommendations 2-1 and 2-2).
  • Identify specific opportunities to braid the funding of research and practice so that the impact of programs and practices that are being funded by service agencies, such as the Substance Abuse and Mental Health Services Administration (SAMHSA), are experimentally evaluated through research funded by such agencies as NIH or the Institute of Education Sciences (IES) (see Recommendation 12-2).
  • Consider the potential to develop a standardized system to measure core promotion and prevention outcomes that could be used and adapted by states and communities across the country to monitor performance, potentially building on existing community monitoring systems.
  • Oversee the development and implementation of consistent, rigorous standards of evidence for endorsement of prevention programs (see Recommendation 12-4).

Both service and research components of the relevant agencies should be involved. These include, in the U.S. Department of Health and Human Services, NIH, SAMHSA, the Health Resources and Services Administration, the Administration for Children and Families, the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Prevention, and the Office of the Assistant Secretary for Planning and Evaluation; in the U.S. Department of Education, IES and Safe Schools; and in the U.S. Department of Justice, the Office of Juvenile Justice and Delinquency Prevention and the National Institute of Justice. The need for high-level coordination across multiple agencies, the broad implications of healthy development for multiple components of society, and the significant cost associated with MEB disorders call for ongoing White House involvement. The White House has played a leadership role in other related issues, such as violence against women, mental health policy (the New Freedom Commission), strengthening youth, and drug control policy. A new, ongoing interagency mechanism focused on the emotional and behavioral health of young people could build on and extend the current White House effort to help America’s youth. This current effort, a “nationwide effort to raise awareness about the challenges facing our youth, particularly at-risk boys, and to motivate caring adults to connect with youth in three key areas: family, school, and community,”2 already recognizes many of the core findings outlined in this report.

The specific mechanism could take many forms, including a new White House office, an ongoing commission, or a White House–led strategic coordinating group. Regardless of the form it takes, it should have adequate authority to direct agency resources in a coordinated manner, facilitate a paradigm shift that emphasizes promotion and prevention, and have a long-term mandate.

Just as there have been significant advances in prevention science in the past 15 years, it is highly likely that there will be considerable progress in the next 15 years with the development of new, more refined prevention strategies. The nation should have a mechanism in place to benefit from rapid deployment of these advances. The creation of an ongoing strategic mechanism to coordinate federal efforts will facilitate consideration of how these advances are best applied. A major need for the immediate future is to systematically study how to effectively translate these strategies to broad-based prevention programs and to identify mechanisms for federal support of community and state efforts. The time is ripe for interventions to be delivered and tested in primary care, in the mental health care sector, in schools, in community organizations, and in families.

Mental health efforts are often fragmented and of uneven quality for children, youth, and families, as they are for adults (Institute of Medicine, 2006b) and for physical health care (Institute of Medicine, 2001). In the long run, consideration needs to be given to an effective, broad-based, strong public health network that can provide adequate data to monitor progress and support the delivery of high-quality preventive services focused on mental and physical health in a variety of sectors. Linked services for the promotion of mental and physical health can respond to the growing recognition that mental health is dependent on good physical health and vice versa.

The committee was struck by the pervasive role played by poverty in development of a range of MEB disorders and related problems. Similarly, the health care system in the United States, which limits access to and quality of care for many of the most poor and disenfranchised, complicates effective prevention. National attention should be paid to narrowing income and health care disparities as a fundamental part of the promotion of mental health and prevention of MEB disorders.


Prevention science has identified the major malleable risk factors for the development of most MEB disorders and related problems. The number of efficacy trials and the experimental and statistical methods needed to make reliable conclusions have exploded since 1994. Numerous interventions have been tested in two or more randomized controlled trials, and several have been tested in multiple U.S. communities or implemented nationwide in European countries.

The inability of the mental health care system to respond to the demands for treatment is well documented. Many young people receive treatment in systems outside the formal mental health care system, such as schools, primary medical care, child welfare, and criminal justice. Not all cases of MEB disorder can be prevented, but a concerted effort to determine the proportion of such disorders that can be prevented is now possible. Shifting the focus toward prevention may help alleviate pressures on treatment resources; this would need to be empirically tested through community- or statewide implementation of prevention.

The mental, emotional, and behavioral health of young people cannot, and should not, be the responsibility of the mental health care system alone. Improvements or potential savings from effective prevention inherently benefit systems other than, or in addition to, the system implementing an intervention. Similarly, the failure of one system involved in a young person’s life can have costs for another. For example, there is evidence that improving social and emotional functioning improves academic outcomes. Interventions involving both families and schools seem to have a high level of success. Increasingly, parents are bringing their children to physicians’ offices with behavioral concerns. Schools and primary care settings may be less stigmatizing for children and families and may enable exploration of emotional and behavioral health issues more openly than a mental health setting.

Successes in other areas, such as prevention of smoking, suggest that approaches that involve complementary components at multiple levels are needed. Involving multiple community systems has the potential to leverage resources and implement approaches that support young people throughout their development rather than only in a particular grade or a particular school.

Multiple federal programs have required state and local grantees to implement evidence-based programs. This has both raised awareness regarding evidence-based programs and created a missed opportunity to learn about effective implementation and how adaptation of programs to local circumstances might affect outcomes. This information is needed not only at the national level, but also to inform the community on progress, determine changes needed, and sustain interest in community-wide efforts. Creating systems that support the implementation of preventive interventions, allow their continuous improvement, and facilitate the introduction of new approaches, while evaluating results, should complement national research and planning efforts.

Recommendation 13-3: States and communities should develop networked systems to apply resources to the promotion of mental health and prevention of MEB disorders among their young people. These systems should involve individuals, families, schools, justice systems, health care systems, and relevant community-based programs. Such approaches should build on available evidence-based programs and involve local evaluators to assess the implementation process of individual programs or policies and to measure community-wide outcomes.

Both the identification of problems and resources and the development of solutions will vary by community. However, monitoring systems, a key component of public health, should be integral to any state or community-wide system in order to track the incidence and prevalence of MEB disorders as well as key risk and protective factors and provide information needed to guide efforts. Many states are implementing monitoring systems similar to available national surveys, such as Monitoring the Future, the Youth Risk Behavior Survey, and the National Household Survey of Drug Use and Health (Mrazek, Biglan, and Hawkins, 2004; Boles, Biglan, and Smolkowski, 2006). These surveys provide estimates of substance use and, in some cases, data on adolescents’ self-reported antisocial behavior and high-risk sexual behavior. States and communities need to develop monitoring systems that are capable of providing data on other targeted disorders. In addition, these systems can be used to mobilize support for community-based prevention efforts. For example, annual data on adolescent depression could be used to motivate support for the implementation of evidence-based depression preventions. This requires, however, that data be summarized and delivered to key target audiences in a timely, clear, and useful manner. Web-based systems for delivering this information show great promise (Mrazek, Biglan, and Hawkins, 2004). Ideally, a template for a community monitoring system would be developed at the national level and available to all communities, and the national system recommended by the committee (see Chapter 2) would adopt use of unique identifiers to enable use by state and local networks.


National and state systems will have to be supported by adequate monitoring systems, funding, and trained personnel. In addition, rigorous standards must be developed and implemented to provide clear guidance to states and communities on the readiness for implementation of specific interventions. The committee’s recommendations call for action in each of these areas by federal agencies and by relevant training programs.

  • Monitoring system. There is a need to develop approaches to report on the prevalence of disorders and key risk and protective factors and to report on the utilization of mental health care services across multiple service systems that work with young people (see Chapter 2).
  • Standards. Federal and state agencies need to identify and prioritize the use of evidence-based programs by applying scientific criteria to assess programs (see Chapter 12).
  • Funding. Federal agencies need to increase resources to states and local communities to implement approaches to prevention, ideally partnered with research funding, targeted to communities with greatest need (see Chapters 8, 11, and 12).
  • Training. Guidelines, model training programs, and accreditation standards are needed for training both researchers and practitioners on prevention of MEB disorders and promotion of mental health. Research training programs that facilitate creation of multi-disciplinary training teams will advance translational prevention research efforts aimed at integrating developmental neuroscience and preventive intervention research (see Chapters 5 and 12).


Substantial progress has been made since the 1994 IOM report in identifying mechanisms to affect risk or protective factors for MEB disorders, developing specific approaches to affect those factors, and strategies to prevent specific disorders, such as depression and substance abuse. However, despite the high prevalence of MEB disorders and the promise apparent from prevention research, research on prevention has not received attention or funding commensurate to that of treatment research.

Recommendation 13-4: Federal agencies and foundations funding research on the prevention of MEB disorders should establish parity between research on preventive interventions and treatment interventions.

Multiple federal agencies, across several departments, fund research related to prevention. Research priorities differ across agencies, making it difficult to systematically identify and address new research needs. Continued progress over the next decade and the nation’s ability to reduce the prevalence of disorders will require that efforts to implement what is currently known are married with rigorous efforts to address gaps in research knowledge.

Recommendation 13-5: The National Institutes of Health, with input from other funders of prevention research, should develop a comprehensive 10-year research plan targeting the promotion of mental health and prevention of both single and comorbid MEB disorders. This plan should consider current needs, opportunities for cross-disciplinary and multi-institute research, support for the necessary research infrastructure, and establishment of a mechanism for assessing and reporting progress against 10-year goals.

Several specific recommendations related to gaps in research knowledge have been identified throughout the report and should be considered in development of this plan:

  • Screening. Approaches needed to develop and test models for screening in school and primary care settings (see Chapter 8).
  • Intervention effectiveness. Development of new and more effective interventions, as well as research aimed at replicating findings with a range of target populations and demonstrating outcomes over time, ideally across developmental phases (see Chapters 7 and 10).
  • Multi-institute collaborations. Collaborative funding of interventions that target risk factors common to multiple disorders and assess multiple outcomes (see Chapters 4 and 12).
  • Cultural relevance. Research on how interventions developed with one cultural or ethnic group work with other groups (see Chapter 11).
  • Economic analyses. Need for guidelines, measures, and funding for economic analyses (see Chapter 9).
  • Dissemination and implementation. Methodologies and strategies for dissemination and implementation of preventive interventions, including research on (1) state- and community-wide implementation, (2) alternative approaches to implementation that vary such factors as type of provider or training, (3) potential strategies for use of the mass media and Internet, and (4) identification of program components that might facilitate implementation (see Chapter 11).
  • Competencies. Need for improved understanding of etiology and development of competencies, their protective role, and development of measurement tools (see Chapter 4).
  • Neuroscience and prevention. Approaches to linking findings from brain research and research on gene–environment interactions with intervention research, to test hypotheses related to epigenetics and neuroscience, and development of guidelines on ethics of using individually identifiable information (see Chapter 5).
  • Gaps in current research. Interventions for such groups as young adults and young people with chronic health problems, in such settings as primary care, comprehensive interventions, and approaches to addressing poverty (see Chapters 6 and 7).

To assist in the implementation of a prevention research agenda and to help distinguish prevention research from treatment research, this report calls on the prevention community to adopt a definition of prevention that focuses on populations that do not currently have a disorder, including three levels of intervention: universal (for all), selective (for groups or individuals at greater than average risk), and indicated (for high-risk individuals with specific phenotypes or early symptoms of a disorder). However, it also calls on the prevention community to embrace mental health promotion as within the spectrum of mental health research. In addition, prevention researchers are advised to broaden the focus of their research to include consideration of cost-effectiveness and the impact of interventions on multiple outcomes.


The scientific foundation has been created for the nation to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships with others. Implementation of the recommendations of this report will move it firmly in the direction of such a society.

This movement can be guided by a vision of what families, schools, neighborhoods, health care providers, and community organizations could be like. There would be a well-organized system of organizations, programs, and policies to ensure strong families and schools and nurturing neighborhoods. Young people would have access to high-quality, well-administered schools, access to health care and other community services, and healthy environments, activities, and food. The system would include the following elements specific to prevention:

  1. Factors shown to improve the physical and mental health of children and their caregivers are explicitly addressed by the systems that provide services to them. Responsibility for and investment in interventions affecting children’s development and long-term futures is shared by multiple service systems, including education, child welfare, primary care, and mental health.
  2. Families and children have ready access to the best available evidence-based preventive interventions, delivered in their own communities in a culturally competent and respectful (nonstigmatizing) way.
  3. Preventive interventions are provided as a routine component of school, health, and community service systems, reducing stigma to a minimum.
  4. A well-organized public health monitoring system is in place at the national and community levels to track the incidence and prevalence of MEB disorders in young people and used to appropriately direct resources as well as to monitor the cost and impact of prevention and treatment efforts.
  5. Services are coordinated and integrated with multiple points of entry for children and their families (e.g., through schools, health care settings, and community-based organizations, such as youth centers and churches).
  6. As further new discoveries, interventions, or adaptations occur, including such innovations as the use of the Internet for preventive purposes, these are incorporated into already existing networks for the delivery of services.
  7. Families are informed that they have access to resources when they need them without barriers of culture, cost, or type of service.
  8. Families and communities are partners in the development and implementation of preventive interventions and learn to manage their access and utilization of prevention services.
  9. The development and application of appropriate preventive intervention strategies contribute to narrowing rather than widening health disparities.
  10. Teachers, child care workers, health care providers, and other professionals who work with young people are routinely trained on approaches to support the behavioral and emotional health of young people and the prevention of MEB disorders.

The type of system envisioned above, which routinely provides universal interventions that support healthy development for all and systematically identifies groups and individuals at greater risk to provide them with specific services, could result in very different outcomes for the nation’s young people. Table 13-1 illustrates what a system might look like at various developmental phases.

TABLE 13-1. Examples of Potential Components of a Prevention System That Supports Developmental Phases.

TABLE 13-1

Examples of Potential Components of a Prevention System That Supports Developmental Phases.

International Perspectives

The committee was impressed with evidence showing that some of the prevention advances being suggested for the United States are already in place in other developed nations. A comprehensive review of international policies and programs is outside the scope of this report. However, a brief discussion and a few examples illustrate that our recommendations are not merely utopian dreams, but rather a call for the nation to make available to children and families the types of services and initiatives that are already being implemented in other countries.

Europe as a whole is working toward a comprehensive strategy on mental health, with a strong focus on mental health promotion and the prevention of MEB disorders (Jané-Llopis and McDaid, 2005). As this process unfolds, it could inform how the United States should integrate prevention into systems at the federal, state, and local levels while taking into account the distinct needs of different communities. At the World Health Organization Ministerial Conference on Mental Health in 2005, member states of the European Region endorsed a European Action Plan for Mental Health that includes the promotion of mental health and prevention of mental illness (World Health Organization, 2005). In support of the implementation of the action plan, the European Commission produced a Green Paper on Mental Health. This document outlined a framework to increase the coherence of health and nonhealth policies in support of mental health at the level of member states and communities (Commission of the European Communities, 2005). The green paper launched a process that included consultation with relevant European institutions, governments, health professionals, and stakeholders in the research community and other civic sectors (Commission of the European Communities, 2005). These deliberations on mental health include a strong emphasis on mental health promotion and prevention of mental illness.

To work toward developing a comprehensive strategy to address promotion and prevention in mental health, 29 European countries have formed the European Network for Mental Health Promotion and Mental Disorder Prevention. The aim of the network is to serve as an information resource to disseminate evidence-based knowledge and tools and to develop integrated approaches to training, policy, and implementation (Jané-Llopis and Anderson, 2006). Individual countries have linked their prevention programs to the shared policies of the European Union. This includes an emphasis on prenatal programs and a healthy start in life, along with early education programs, which are generally more developed and available than in the United States (Jané-Llopis and Anderson, 2006). In addition, many countries are working to integrate mental health promotion and prevention efforts both with the systems that address physical health and with antipoverty programs, recognizing that poverty is a major factor in the development of MEB disorders (Jané-Llopis and Anderson, 2005).

Many European countries experience challenges to translating this interest in promotion and prevention into action; these challenges are similar to those described in this report, including financing, infrastructure, and implementation support (Jané-Llopis and Anderson, 2006). However, there are also notable successes in nationwide implementation and comprehensive national approaches in Europe and elsewhere that offer promising models from which lessons can potentially be learned.

Some countries have undertaken nationwide or widespread implementation of specific evidence-based programs. For example, Parent Management Training, a program originally developed in the United States, has been adapted in Norway and implemented nationwide through the creation of a national implementation and research center that coordinates training for providers, supervision, consultation, and research in support of implementation with strong partnership at the regional and local levels (Ogden, Forgatch, et al., 2005).

Australia has launched a National Mental Health Promotion, Prevention, and Early Intervention Action Plan (Commonwealth Department of Health and Aged Care, 2000) as part of a multiyear effort to position mental heath as a new strategic direction. It includes the implementation of multiple policies and programs as part of a national effort. As a component of a national initiative on depression, the Triple P Program (a multilevel parenting program; see Chapter 6) was tested on a population level in multiple Australian communities. It demonstrated significant reductions in the number of children with recognizable and borderline behavioral and emotional problems and the number of parents who reported depression, stress, and coercive parenting, although reductions were modest (Sanders, Ralph, et al., 2008).

The Netherlands has a comprehensive national infrastructure for health promotion and prevention that includes public health, mental health, and addiction. This infrastructure includes mechanisms that support research and dissemination of evidence-based programs and involves multiple sectors, such as the health system, the justice system, and schools. It is supported by a specialized professional workforce of trained health promoters and prevention workers, about half of whom are primarily or partly focused on mental health (Jané-Llopis and Anderson, 2006). One of the areas of priority is the care of children of mentally ill parents. The Netherlands, as well as Finland, have implemented country-wide systems to support the children of mentally ill parents in their health care systems (see Box 13-1).

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BOX 13-1

Health System–Based Approaches to Prevention in the Netherlands and Finland. The Netherlands and Finland have both developed system-wide approaches that initially focused on children of depressed parents and now include prevention work with children (more...)

Scotland launched the National Programme for Improving Mental Health and Well Being in 2001. The key aims include raising awareness and promoting mental health and well-being, eliminating stigma and discrimination, preventing suicide, and promoting and supporting recovery from mental illness. The priority areas include, among others, the mental health of infants, children, and young people. The national program includes campaigns; research, evaluation, and training initiatives; monitoring; partnerships; and implementation support at the national level as well as services and partnerships at the local level (Scottish Executive, 2003). It is guided by a National Advisory Council made up of a range of stakeholders from the public and private sectors in a variety of settings, including schools, prisons, and the health system (Jané-Llopis and Anderson, 2006). Information on Scotland’s progress is available at http://www.wellscotland.info/index.html.

Systematic attempts to affect the entire population have great value in public health, and integrative models in Europe and other countries may offer efficient approaches to supporting the development of young people, although empirical evidence to date appears to be lacking. Although these models still need more comprehensive study, as the United States moves forward with prevention, federal, state, and local governments should look for evidence-based progress in other countries and applicable lessons learned that can be adapted to systems here.


The gap between what is known and what is being done is far too large. It can be addressed only by continuing to refine the science and by a strong commitment to develop the infrastructure and put in place systems that allow for equitable delivery of preventive interventions on a population-based, large-scale basis. The United States needs to build on the extensive research now available by addressing gaps in the available research and developing a shared vision and strategy for applying the knowledge at hand.

When IOM’s report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research was published in 1994, the majority of available studies were efficacy studies, with a few addressing the effectiveness of interventions. The report called on the field to continue to develop rigorous efficacy and effectiveness evaluations while at the same time moving further toward the final stage in the proposed prevention research cycle to “facilitate large scale implementation and ongoing evaluation of the preventive intervention program in the community.” It is now clear, however, that achieving community ownership and implementation of science-based preventive interventions is not only an issue of dissemination of information about effective interventions, but also a matter of empirically evaluating strategies achieving effective adoption, implementation, and maintenance of evidence-based preventive interventions. The next major milestone will be the translation of existing knowledge into population-wide reductions in the incidence and prevalence of emotional and behavioral problems. One of the areas of greatest need is to develop strategies and outcome measures to ensure that high-quality evidence-based approaches are successfully adapted for use in a broad array of different cultural, ethnic, and linguistic settings. As research on development and implementation of specific interventions continues, states and communities need to also continuously refine effective interventions and implementation approaches.

Similarly, while there has been sustained research over the past 15 years, we recommend attention to areas that have heretofore been neglected, such as effectiveness in real-world situations, cost-effectiveness, integration of genetics and neuroscience with intervention research, and the careful monitoring of rates of disorder and present risk factors to assess whether population-based improvements can be achieved. Without adequate surveillance, what the burden of disorder is for the society or where best to direct national resources will not be fully known.