NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

National Research Council (US) and Institute of Medicine (US) Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions; O'Connell ME, Boat T, Warner KE, editors. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington (DC): National Academies Press (US); 2009.

Cover of Preventing Mental, Emotional, and Behavioral Disorders Among Young People

Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities.

Show details

12Prevention Infrastructure

The development and ultimate success of efforts to improve mental, emotional, and behavioral outcomes among young people depend heavily on the availability of systems to support efforts in three domains: research and innovation, training, and delivery of successful interventions. This chapter addresses three key interconnected topics: (1) funding for research, training, and service delivery programs; (2) the adequacy of access to prevention delivery systems; and (3) content of training programs directed to enhancing the prevention workforce.

The chapter begins with a discussion of federal funding, highlighting the challenges in determining the level of funding for either prevention research or services, indications that the federal commitment to prevention research may have waned since the publication of Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (Institute of Medicine, 1994), and the lack of systematic coordination of either research or service delivery efforts. It then moves to issues related to the development of prevention delivery systems, including discussion of multiple federal efforts related to prevention and promotion, the need for consistent, rigorous standards to identify effective interventions, and illustration of some existing state and local efforts to develop delivery systems. The chapter closes with discussion of gaps in prevention-specific training in a range of disciplines, pointing out that prevention efforts are likely to continue to languish without targeted attention to preparing the future prevention workforce.

FUNDING

It is difficult to quantify current funding for either prevention research or prevention services, due to the many agencies involved, varied definitions and tracking systems used by agencies, and the multiple levels of service funding and delivery. In some cases, prevention is a piece of a larger program or an eligible activity under a block grant, but there is no specific accounting of the proportion targeted to prevention. Similarly, programs that fund services aimed at addressing factors that contribute to prevention of mental, emotional, and behavioral (MEB) disorders clearly have an important role to play in prevention, but they cannot fairly be claimed as prevention programs in their entirety—for example, child abuse prevention programs. In addition, there is no national network or organization that coordinates all preventive efforts, either for research or services, from which funding estimates can be generated. While more states and counties have been investing in prevention activities, the scope of that investment has not been monitored systematically.

Research Funding

Multiple components of the U.S. Department of Health and Human Services (HHS), including the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), the Maternal and Child Health Bureau (MCHB), the Centers for Disease Control and Prevention (CDC), and the Administration for Children and Families (ACF) fund prevention research involving young people. The research arms of the U.S. Department of Education (ED) and the U.S. Department of Justice and private foundations also fund relevant research. Published randomized controlled trials (see Figure 1-1) tend to be funded primarily by HHS. Of those with an identified funding source,1 almost three-quarters (74 percent) received some funding from HHS; more than half (57 percent) received all of their funding from HHS. Given that NIH is the largest source of research funding in HHS, particularly for randomized controlled trials, it is reasonable to assume that they are the primary source of this funding. Only one in four published randomized controlled trials received all of its funding from a non-U.S. government source, such as foundations or foreign governments.

National Institutes of Health

NIH publishes online their estimates of funding for various diseases, conditions, and research areas. Although the amount spent on “prevention” declined overall from $7.185 billion in fiscal year (FY) 2004 to $6.739 billion in FY 2009, this includes all NIH institutes, so it is impossible to say to what extent this applies to prevention of MEB disorders among young people (see http://www.nih.gov/news/fundingresearchareas.htm). Determining federal research funding for prevention in this area is also complicated by the current system for categorizing and reporting grants, which lacks a common definition of prevention. This situation exists despite a definition of prevention accepted by the NIH Prevention Research Coordinating Committee,2 updated in 2007.

NIH is nearing the end of a project to establish an NIH-wide system for coding funded projects, the Research, Condition, and Disease Categorization (RCDC) system.3 This system has been developed in response to a requirement that was added to the NIH Reauthorization Act in 2006. It will be able to produce a complete annual list of all NIH-funded projects related to each of 360 categories, including prevention, using standard definitions that will be used across all NIH centers and institutes. Projects will be coded for all applicable categories to allow for funding information to be searched and cross-referenced by multiple categories. The first funding report is expected to be available on a public website in spring 2009 for project funding in FY 2008, and it will not be applied retroactively to previous years. Once in place, this new system should improve the availability of consistent, accurate information on NIH funding for the prevention of MEB disorders. It is unclear, however, how prevention will be defined for the RCDC system.

Furthermore, there are no plans for the RCDC system to provide linkage to financial data, limiting opportunities to quantify the federal investment in prevention research.

NIMH, NIDA, and NIAAA Funding

The National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) are the NIH institutes with direct responsibility for research related to prevention of MEB disorders, and they are a significant source of funding for intervention research. The National Institute of Child Health and Human Development (NICHD) also plays a critical role in exploring developmental pathways and healthy development of young people. The committee requested historical data on prevention and treatment research and narrative information on FY 2006 funding from NIMH, NIDA, and NIAAA. However, these institutes were not able to provide uniform data and, with the exception of NIMH, were not able to provide longitudinal data. None routinely tracks its prevention research projects as universal, selective, or indicated.

NIMH was able to provide the most comprehensive financial data. Although both prevention and treatment intervention research funding increased between 1999 and 2006, prevention intervention research funding represented a smaller proportion of the overall NIMH budget than treatment intervention research (6.62 percent versus 8.75 percent, respectively, in FY 2006). If research aimed at “prevention of negative sequelae of clinical episodes, such as comorbidity, disability, and relapse or recurrence” were classified as treatment intervention research, consistent with the committee’s definitions of prevention and treatment (see Chapter 3), the discrepancy between funding for prevention (6.72 percent in 2006) and treatment intervention research (14 percent in 2006) would be considerably greater (see Figure 12-1). In addition, both the percentage increase between 1999 and 2006 (80 and 102 percent for prevention and treatment intervention research, respectively) and the total funding ($94.4 and $122.8 million, respectively, in FY 2006) were much less for prevention than for treatment intervention research.

FIGURE 12-1. Proportion of NIMH budget for prevention and treatment in intervention research.

FIGURE 12-1

Proportion of NIMH budget for prevention and treatment in intervention research. SOURCE: Committee analysis of data provided by NIMH.

Consistent with the 1994 Institute of Medicine (IOM) report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research funding for prevention research4 on drug abuse was proportionately greater than the funding for prevention research on mental disorders. Between 1999 and 2006, the proportion of NIDA’s total appropriation expended for prevention ranged from 13.4 to 14.5 percent, while that of NIMH ranged from 5.7 to 7.6 percent during the same time period. The vast majority of NIAAA prevention research in FY 2007, the only year for which estimates were provided, focused on underage drinking.

Organizational Structure. When the 1994 IOM report was published, NIMH, NIDA, and NIAAA each had a prevention research branch; only NIDA has one today. The NIDA prevention research branch remains in the Division of Epidemiology, Services, and Prevention Research (previously called the Division of Epidemiology and Prevention Research). NIAAA now has a Division of Epidemiology and Prevention Research, which works collaboratively with other divisions. NIMH has established an associate director position in the Office of the Director with coordinating responsibilities related to prevention. The position, however, has no funding authority. NIMH does have a Child and Adolescent Treatment and Preventive Intervention Research Branch, which funds many of its prevention research projects; HIV prevention programs are funded out of its Primary Prevention Branch.

Research Centers. NIMH, NIDA, and NIAAA also fund university-based prevention research centers5 (see Table 12-1). The centers conduct training and research related to a range of prevention-related issues, largely focused on young people. The number of NIMH-funded centers decreased from five to three between FY 1993 (the last year included in the 1994 IOM report) and FY 2006.

TABLE 12-1. Prevention Research Centers.

TABLE 12-1

Prevention Research Centers.

NIDA currently funds five Transdisciplinary Prevention Research Centers (TPRCs) designed to bring together the expertise of basic and applied disciplines to accelerate the development and implementation of preventive interventions. Neuroscientists, behavioral and cognitive scientists, and drug abuse prevention researchers collaborate on discovery and translational research areas that have the potential for producing new approaches to drug abuse prevention. Similar mechanisms do not currently exist in NIMH or NIAAA or across the three institutes. NIAAA funds two prevention centers: the long-standing Prevention Research Center based at the University of California, Berkeley, and a new center focused on youth alcohol prevention.

Intervention Research Portfolio Snapshot. The FY 2006 abstracts for projects focused on young people (ages 0–25)6 provide a one-year snapshot of NIMH, NIDA, and NIAAA prevention intervention research funding. Abstracts were coded by two reviewers on a variety of categories, including intervention type (universal, selective, indicated), trial type (efficacy, effectiveness, implementation), targeted risk factors, outcomes, and mediators; targeted population; and the location and provider of the intervention.7 The coding results were analyzed for 35 NIMH abstracts, 77 NIDA abstracts, and 53 NIAAA abstracts.

We conclude from this analysis (see Box 12-1) that there is an emergence of effectiveness trials, but a lack of research that experimentally evaluates factors influencing implementation and dissemination of interventions. Appendix F provides a detailed summary of the analysis results.8 The analysis argues for greater attention to economic analyses as well as evaluations that assess multiple outcomes. The current research portfolio does not address gaps identified by the committee, including the need to expand research to cover more settings that provide opportunities to prevent MEB disorders, greater attention to cultural appropriateness and adaptation, and interventions for young adults.

Box Icon

BOX 12-1

Prevention Intervention Research at NIMH, NIDA, and NIAAA, Fiscal Year 2006. Intervention Type and Trial Type NIDA and NIAAA funded a greater proportion of universal intervention trials than NIMH.

Centers for Disease Control and Prevention

CDC has an active public health research portfolio that includes a focus on child development. In its 2006 publication Advancing the Nation’s Health: Guide to Public Health Research, 2006–2015, health promotion is one of six specified areas, although the role of mental health promotion is unclear. In the area of health promotion, creating healthy schools is one of the target areas. In addition, CDC provides funding for Community-Based Participatory Prevention Research, although prevention of MEB disorders among young people has been a relatively small component of funded projects.

Private Foundations

Currently, apart from religious congregations, total annual charitable expenditures in the United States are about $1 trillion. Depending on funding priorities, the amount of this investment should grow substantially, possibly more than double, as an unprecedented intergenerational transfer of wealth is predicted to occur between 1998 and 2052 (Fleishman, 2007). This will provide an opportunity to increase research for prevention of MEB disorders, especially if foundation boards are educated about the social and economic costs of mental disorders at a time when the United States needs a strong and productive workforce. Some private foundations already support preventive services and research related to mental, emotional, and behavioral problems among young people. Information on the amount of this investment is unavailable, but it is likely to be modest.9

Preventive Services Funding

There are no current estimates of overall national spending on preventive services. The most recent estimate concluded that in 1995 federal agencies contributed $1.8 billion, state Medicaid contributed $1.3 billion, and employee assistance/wellness programs contributed $1.2 billion toward the prevention of mental illness (Harwood, Ameen, et al., 2000). This would translate to $5.9 billion in 2007 dollars.

Federal Investments

Similar to the situation at the time of the 1994 IOM report, multiple federal agencies fund programs and services related to the prevention of MEB disorders. Although few are directly targeted to this task, there are many more federal efforts to encourage prevention and promotion activities than was the case in 1994, particularly activities targeted to mental health activities in schools.

The lead federal agency and largest funder of prevention of mental health disorders and substance abuse is the Substance Abuse and Mental Health Services Administration (SAMHSA). Within SAMHSA, this falls to the Center for Substance Abuse Prevention (CSAP) and the Center for Mental Health Services (CMHS), primarily through its Division of Prevention, Traumatic Stress and Special Programs. Unlike CSAP, which has the Center for Substance Abuse Treatment as a sister agency, CMHS must address both treatment and prevention issues. Other major federal funding sources include the Office of National Drug Control Policy, MCHB, ED (including such initiatives as Safe and Drug-Free Schools10), and the Office of Juvenile Justice and Delinquency Prevention. ACF is the primary funder of Head Start and child welfare programs, and CDC is involved in suicide prevention programs and surveillance efforts.

In 2004, SAMHSA awarded $230 million over 5 years to 21 states for the creation of Strategic Prevention Frameworks (Substance Abuse and Mental Health Services Administration, 2004), an approach to planning and implementing prevention programs, broadly based on principles drawn from research. These funds are helping states to build the infrastructure and processes needed to promote healthy youth development, reduce risky behaviors, and prevent problem behaviors through community programs.

Although there are block grants for both mental health (Mental Health Services Block Grant) and substance abuse (Substance Abuse Prevention and Treatment Block Grant), only the substance abuse block grant includes a set-aside for prevention. States are mandated to use 20 percent of their block grant resources for universal, selective, and indicated prevention activities. In FY 2001, SAMHSA/CMHS awarded targeted capacity expansion grants for prevention and early intervention services, but the program has not been continued.

In 2006, Safe and Drug-Free Schools at ED appropriated $510 million for numerous programs targeting prevention of mental disorders and substance abuse. These programs focus on preventing illegal drug and alcohol use among youth and creating violence-free educational environments for both school- and college-age youth. Grants for the integration of Schools and Mental Health Systems aim to increase linkages between schools, mental health, and juvenile justice authorities to improve access to quality mental health services, including preventive services. ED also provides grants to assist local education authorities develop “innovative and effective” alcohol abuse prevention programs.

Increased concern about violence also led to the creation in 1999 of the Safe Schools/Healthy Students (SSHS) Program, a collaboration of HHS, ED, and Justice. Through this program, local education agencies receive three-year grants to work in partnership with local law enforcement and mental health agencies to develop a comprehensive approach to violence prevention that includes safe school environments; violence, alcohol and drug, and mental health preventive services; early childhood services; and treatment services. Over 150 communities have been funded through this program.

SAMHSA also administers the majority of service grants aimed at preventing suicide through the Garrett Lee Smith Memorial Act Suicide Prevention Program, which provides grants to states and colleges and funds a technical resource center.

In FY 2008, SAMHSA announced a new grant program, Project Launch (Linking Actions for Unmet Needs in Children’s Health), which is designed to promote the physical, emotional, social, and behavioral health of young children from birth to age 8. The grants will be provided to state or tribal governments for a wide range of early childhood service programs. The program is being implemented in collaboration with the Health Resources and Services Administration (HRSA).

The MCHB at HRSA continues to be active in encouraging integration of mental health and physical health concerns. For example, its Early Childhood Comprehensive Systems Grant Program includes “mental health and social-emotional development” as one of five core components. It administer the Healthy Start Program and several other programs aimed at improving the health and social-emotional functioning of young people.

ACF administers the Head Start and Child Abuse Prevention Programs and recently included prevention-related activities in a component of the Compassion Capital Fund. In addition to its involvement in the SSHS Progam, the Department of Justice, primarily through its Office of Juvenile Justice and Delinquency Prevention, operates multiple grant programs aimed at delinquency prevention, violence prevention, and truancy reduction. CDC conducts surveillance and funds coordinated school health programs aimed at integrating eight health components, including mental health and social services. Finally, the Office of National Drug Control Policy awards drug-free communities grants and administers a national antidrug media campaign.

Many federal prevention funds operate as competitive grants of limited duration. This can lead to problems, such as inadequate or interrupted funding, that impact the ability to sustain interventions (see Chapter 11).

Federal Coordination

HHS, ED, and Justice appear to have mechanisms in place to support the planning, implementation, and technical assistance associated with the SSHS Program (U.S. Government Accountability Office, 2007) and other targeted initiatives. However, there does not appear to be an obvious connection between ED’s several programs and SAMHSA’s Strategic Prevention Framework. Similarly, although there are multiple relevant interagency groups, including the Federal Executive Steering Committee on Mental Health, the Federal/National Partnership, which includes an integrating mental health and education and suicide prevention work-group, the Coordinating Council on Juvenile Justice and Delinquency, an interagency coordinating group on underage drinking, the Department of Labor’s Shared Youth Vision, and the White House–led helping America’s Youth initiative, there is no apparent coordination among the groups or a clear sense of their distinct or complementary missions. Similarly, although there has long been an Office of Prevention Research in the Office of the Director at NIH, it has apparently limited linkage to activities at the various institutes or agencies involved in MEB disorders.

Both CDC and HRSA have established Mental Health Work Groups. However, there was no evidence that the two groups are aware of each other’s activities, and it is not clear the extent to which these group have considered prevention or interact with the various other interagency groups.

State Investments

Some states also dedicate significant amounts of state resources to prevention. One example of significant state-level preventive mental health funding can be found in California, which passed its Mental Health Services Act in 2004. This act is funded by a 1 percent tax on personal incomes over $1 million and had generated $2.1 billion in additional revenues for mental health services through the end of FY 2006–2007, with an additional $1.5 billion expected in each of the next two fiscal years (California Department of Mental Health, 2008). As part of this initiative, California has recently completed expenditure and program planning guidelines for counties statewide to address mental health promotion and prevention for youth and their families (California Department of Mental Health, 2007). As of May 2008, over $300 million had been committed for prevention and early intervention11 (California Department of Mental Health, 2008).

Another example is the Pennsylvania Commission on Crime and Delinquency’s Research-Based Programs Initiative, which began funding replications of efficacious prevention programs a decade ago. In the late 1990s and early 2000s, 110 communities received state funding to supplement federal Title V funding to implement Communities That Care. Approximately two-thirds continued to operate four years after the initial implementation phase (Feinberg, Bontempo, and Greenberg, 2008). Even more communities have been funded to implement research-based violence prevention or substance abuse prevention programs. The state has also established a technical assistance and training center to provide resources needed to facilitate quality implementation by communities.

In another example, Kentucky is devoting 25 percent of its Phase I Tobacco Settlement resources to an early childhood initiative that includes maternal and child health–related activities, voluntary home visitation, Healthy Start, and other developmentally oriented initiatives.12 In late 2007, the state of Illinois announced that it would begin reimbursing community mental health providers for perinatal depression screening, which, if paired with interventions for the mother, could result in improved outcomes for her children. The state similarly accepts infants of mothers diagnosed with maternal depression into its early intervention program.

Some states are also making their own investments in early care and early childhood education services. For example, Illinois, Rhode Island, and North Carolina have each dedicated state resources to initiatives that include expanded child care, parenting, or prekindergarten programs (Mitchell and Alliance for Early Childhood Finance, 2005). In addition, most schools have various efforts in place to address the mental health needs of students, including universal interventions for all students, typically by patching together multiple funding streams (U.S. Government Accountability Office, 2007).

Networks of state and local agencies related to prevention of alcohol and drug abuse are better established than for mental health. For example, the National Association of State Alcohol and Drug Abuse Directors convenes the National Prevention Network, an organization of state-level agencies involved with alcohol and drug abuse prevention. A similar organization, Community Anti-Drug Coalitions of America, advances a community-level focus on drug and alcohol prevention. The National Association of State Mental Health Program Directors does not currently have a comparable prevention-oriented structure. However, other groups, such as Mental Health America, have been advocating at local, state, and national levels for expansion of prevention programs related to mental health.

Insurance

Health insurers, both public and private, also have the potential to fund preventive services for MEB disorders, although it is not clear to what extent this is currently happening. Given turnover in enrollees, private insurers may have little incentive to cover preventive services that yield long-term benefits. However, Dorfman and Smith (2002) reviewed preventive mental health and substance abuse programs and concluded that six types of preventive interventions would be appropriate for a managed care organization to deliver from both a cost-effective and feasibility perspective. These interventions include four programs that would benefit children and adolescents: prenatal and infancy home visits, smoking cessation counseling for pregnant smokers, targeted short-term mental health therapy, and brief counseling to reduce alcohol use. A combination of screening, brief intervention, referral, and treatment is one Medicaid-eligible service that includes early intervention for those at risk for developing substance abuse disorders.

SAMHSA recently reported the results of a study on barriers to and recommendations for reimbursement of mental health services in primary care settings, focusing on services for those with public insurance (Kautz, Mauch, and Smith, 2008). The report highlights a number of barriers that apply to both preventive and treatment services, including limitations on same-day billing for physical and mental health services, limitations on reimbursement for mental health services provided by primary care practitioners rather than mental health specialists, lack of reimbursement for collaborative care and case management, lack of reimbursement for services provided by nonphysician practitioners, and inadequate reimbursement for services in rural and urban settings. The report also specifically identifies the lack of reimbursement incentives for screening and for providing preventive mental health services as a priority barrier (Kautz, Mauch, and Smith, 2008).

Reimbursement for services is sometimes limited by the choices of state Medicaid offices, by local carriers of intermediaries’ interpretations in processing claims, and by specific private insurance plans. Delivery of behavioral health services is frequently covered only if the services qualify as a “medical necessity,” which may vary in definition in managed care contracts and may vary for different services and by different state Medicaid programs and private insurance plans (Kautz, Mauch, and Smith, 2008; Nitzkin and Smith, 2004). For preventive services, the combination of limited available billing codes and the limitations on what is interpreted to qualify as a reimbursable billed service can lead in practice to very restricted reimbursement for preventive services. This contributes to inadequate provision of preventive services by primary care practitioners or promotion of these services by health care systems (Nitzkin and Smith, 2004). In Clinical Preventive Services in Substance Abuse and Mental Health Update: From Science to Services (Nitzkin and Smith, 2004), SAMHSA provides more detailed suggestions for primary care physician reimbursement for preventive services.

There is also only limited reimbursement for mental health services, including preventive services, in schools. Schools can be reimbursed by Medicaid for some mental health services provided to eligible students in special education as well as through school-based health centers. However, these centers can bill Medicaid for these services only if they are provided by enrolled Medicaid providers. Enrollment is not often supported by the administrative capacity of many of these centers, and available providers may not be eligible. In addition, a very small percentage of schools have school-based health centers. Most provide health services directly by school employees (e.g., nurses, psychologists) who can receive only limited Medicaid reimbursement through agreements that vary from state to state (Kautz, Mauch, and Smith, 2008). And 20 percent of public schools report Medicaid reimbursement as a funding source for preventive mental health services (Foster, Rollefson, et al., 2005).

Addressing these obstacles to adequate reimbursement from both private and public payers is one necessary step toward improving preventive services for MEB disorders in primary care and at the interface between primary care and the school system, two of the major entry points for children and families in need of these services.

Some of the identified barriers to reimbursement are amplified by misunderstanding or misinterpretation of covered services and reimbursement rules and could be addressed through clarification of and education about reimbursement policies and definitions, especially in cases in which interpretations at the state and local level may be narrower than federal law (Kautz, Mauch, and Smith, 2008). Some states have also taken advantage of both improved clarity and flexibility in designing Medicaid benefits using Medicaid waivers to achieve improved coverage for mental health services; these can serve as models for change in other states. Other reimbursement barriers would require an expansion of allowable coverage by both publicly and privately funded insurance to increase reimbursement for mental health services that include prevention and screening (Kautz, Mauch, and Smith, 2008; Nitzkin and Smith, 2004).

SYSTEMS THAT SUPPORT DELIVERY OF PREVENTIVE SERVICES

In addition to the provision of funding, federal, state, and local governments can support service delivery systems that provide preventive services by identifying effective interventions as well as by offering technical assistance to community coalitions or organizations.

Identifying Effective Interventions

Federal agencies have sponsored multiple efforts to assess the evidence available related to specific preventive intervention programs. Four federal programs that have analyzed information about preventive interventions are (1) SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP),13 which focuses specifically on programs related to mental health and substance abuse; (2) the Department of Justice’s Model Programs Guide; (3) the White House–sponsored Helping America’s Youth system; and (4) ED’s What Works Clearinghouse. All four list some programs related to prevention of MEB disorders.

Each system has independent processes for rating programs and uses different criteria. The Center for Study and Prevention of Violence compared the ratings assigned by 12 different review efforts; over one-third (34.5 percent) of the 298 programs listed were reviewed by more than one effort. The same program was often given different ratings by different systems; for example, one review assigned its highest rating and another its lowest for the same program.

The NREPP system is somewhat different from the others in that it does not assign an overall rating, but rather assigns a score of 0–4 on multiple criteria and multiple outcomes, leaving it to the user to determine their relevance. One innovative aspect of the system is the inclusion of criteria (implementation materials, training support, and quality assurance) related to readiness for dissemination. The Model Programs Guide of the Department of Justice lists 38 exemplary and 67 effective prevention programs, and NREPP lists 32 reviewed mental health promotion14 and 30 reviewed substance abuse prevention programs.15

In addition to these federally sponsored systems, a number of private and state-level organizations have established online systems to identify effective programs. Blueprints for Violence Prevention (see Chapter 11) is one of the oldest efforts to identify and rate evidence-based violence prevention programs. California has established a clearinghouse for information on recommended child welfare programs, and other states having established more broad-based clearinghouses.

There have also been numerous published reviews, most funded by federal agencies, that identify recommended programs related to juvenile justice (Mendel, 2001; Sherman, Gottfredson, et al., 1997), school-based prevention interventions (Greenberg, Domitrovich, and Bumbarger, 2001; Mihalic and Aultman-Bettridge, 2004), community-based approaches (Communities That Care, 2004), drug abuse prevention (National Institute on Drug Abuse, 2003), youth violence prevention (U.S. Public Health Service, 2001c), and underage drinking (Spoth, Greenberg, and Turrisi, 2008). Programs are given various designations including “effective,” “exemplary,” “promising,” “research-based,” and “model.” In addition, many federally funded technical assistance centers include lists of evidence-based or effective programs on their web pages, often drawing from these many resources.

Increasingly, federal agencies and programs are requiring that program funds be used exclusively for “evidence-based programs.” Guidance of what might be considered evidence-based varies, but generally it includes, but is not limited to, inclusion of a program on one or more federal lists. ACF recently issued a request for proposals to support infrastructure for the delivery of evidence-based home visitation programs, specifically excluding evidence from pre-post designs and programs that did not sustain results after two years.16

The SSHS Program has a somewhat broader set of criteria, defining evidence-based practices or interventions as “approaches to prevention, behavioral intervention, and treatment that are validated by some form of documented scientific evidence to indicate their effectiveness. Programs, practices, and interventions that are based on tradition, convention, belief, or anecdotal evidence are not evidence-based” (Safe Schools/Healthy Students Initiative, 2009, p. 43).

SAMHSA’s guidance to states in selecting interventions to be used under the Strategic Prevention Framework is even broader. In addition to inclusion on a federal list or registry or being reported with positive effects in a peer-reviewed journal, it states that effectiveness can be based on:

  1. a solid theory or theoretical perspective that has been validated by research;
  2. a documented body of knowledge generated from similar or related interventions with empirical evidence; and
  3. a consensus among informed experts (key community prevention leaders, elders, or other respected leaders in indigenous cultures) regarding effectiveness based on a combination of theory, research, and practice experience.

The Society for Prevention Research (SPR) recommended standards for identifying effective prevention programs and policies in response to the proliferation of lists and guidelines. SPR proposed a tiered evidence standard with a basic standard for efficacious interventions, additional requirements for effective interventions, and a yet higher standard for determining that an intervention is ready for broad dissemination (Flay, Biglan, et al., 2005). One of the 31 requirements for an intervention to be designated “effective” is evaluation in real-world conditions (Flay, Biglan, et al., 2005). The importance of this criterion was recently demonstrated by Hallfors, Pankratz, and Hartman (2007), who tested a drug abuse prevention intervention that was designated as a model program by SAMHSA (under the old CSAP system)17 and as “research-based” by NIDA based on efficacy trial data. In a large, multisite effectiveness trial, they showed main effects that were either null or worse for the experimental group compared with the control group. They argue that small efficacy trials provide insufficient evidence for the selection of interventions at the community level (see also Chapter 10).

Linking Research and Services

Identifying strategies for effective implementation of evidence-based programs is a clear future research priority (see Chapter 11). NIH has adopted several efforts to facilitate this process from a research perspective. First, in response to a general lack of knowledge about how to disseminate and implement effective prevention programs, they are convening trans-NIH forums to prepare applicants for new grant programs on dissemination and implementation research that explore characteristics of communities, interventions, and system change that impact prevention outcomes in community settings. Ideally, researchers and community organizations will develop partnerships to move this next generation of research forward in a productive manner.

In addition, NIMH’s agenda for facilitating prevention programs is laid out in the Bridging Science and Service report (National Institute of Mental Health, 2006a) and follow-up reports. It emphasizes linking its agenda on implementation research with ongoing funding of programs by other federal agencies that are responsible for service delivery, including SAMHSA and ED. It specifies that key research questions should focus on mechanisms for successful implementation, particularly with ethnic and minority populations.

Programs designed to fund services typically do not provide adequate funding for rigorous evaluations; when programs are evaluated, they typically do not include random assignment. Although both the SSHS Program and the Strategic Prevention Framework encourage evaluation, there is currently no national evaluation information available. SSHS has published a sample of data from local evaluations, with promising evidence of positive outcomes. These evaluations do not appear, however, in published scientific literature. Improved formal linkages between service and research programs would help build the implementation knowledge base without redirecting service resources toward research and vice versa.

Technical Assistance and Clearinghouses

Federal agencies also provide support for a variety of activities aimed at building the capacity of states, communities, and organizations to provide services aimed at strengthening families, preventing youth risk factors, and designing systems of care. Federal agencies fund numerous technical assistance centers, often linked to specific grant programs (see Box 12-2). Many of the centers provide online guidance on program design, technical assistance and/or training on program design and implementation, and links to other resources. Unlike 1994, when there was “no federal clearinghouse for published information on prevention of mental disorders” (Institute of Medicine, 1994, p. 424), there is now a plethora of resource centers to provide information on preventive intervention. There appears to be no shortage of sources of information, although using them requires navigating through a maze of resources, and selection of the best program to match site variations and desired outcomes may be a daunting task.

Box Icon

BOX 12-2

BOX 12-2 Federally Funded Technical Assistance Centers with a Prevention or Promotion Focus. Center for Effective Collaboration and Practice (ED and HHS/SAMHSA/CMHS) http://cecp.air.org/center.asp

In addition, through its Strategic Prevention Framework, SAMHSA aims to increase implementation of prevention and early intervention programs. Specific to substance abuse prevention, SAMHSA funds five Regional Centers for the Application of Prevention Technologies,18 which provide training and technical assistance and offer a range of online resources through Prevention Pathways.19 Technical assistance resources on the Communities That Care initiative (see Box 11-1) designed to help communities match evaluated programs with local risk and protective factors, are available on SAMHSA’s Strategic Prevention Framework website.20 SAMHSA’s Suicide Prevention Resource Center provides training to strengthen suicide prevention networks, and most of the technical assistance centers provide some level of informal implementation training.

CREATING A TRAINED WORKFORCE

A well-trained workforce, an educated public, and an informed complement of policy makers and funders who will support prevention are all important components of success. For prevention of MEB disorders, the workforce must come from many disciplines, each of which should work synergistically with the others. Training of neuroscientists, psychologists, sociologists, economists, systems engineers, and those in other basic science disciplines to carry out discovery efforts that will fuel new and better prevention interventions continues to be important (see also Chapter 5). Clinicians, including psychologists, social workers, nurses, and physicians, must be prepared to recognize risks and appropriately intervene within the scope of their clinical practice. Finally, teachers and others who work with children on a regular basis should have available training that enhances their knowledge, skills, and attitudes toward prevention of MEB disorders. Thus training and education not only require a broad effort, but also are extraordinarily complex and challenging.

The committee considers core aspects of training to include activities that enhance the knowledge, skills, attitudes, and experience of professionals who will carry out the various elements of programs addressing prevention of MEB disorders. Training must be directed to achieve research capabilities, teaching skills, and the capability to implement prevention programs as well as collect and analyze data on outcomes from such efforts.

The 1994 IOM report contained limited information on training activities in the areas of prevention science and prevention implementation, but it concluded that training needs and output were approximately in balance with workforce needs. It reported a total of 22 NIH-funded research trainee slots per year and estimated that there were no more than 500 professionals conducting prevention research related to MEB disorders. The report roughly estimated that there was a need for approximately 1,000 investigators in the field and proposed that numbers of trainees as well as support for training should gradually increase to match expected growth in this field of investigation.

Based on assessment of progress in prevention training since the 1994 IOM report, the current status of training efforts, and gaps to be bridged, the committee concludes that refinement, translation, and broad implementation of preventive interventions are likely to languish for another 14 years unless more extensive and robust training for both researchers and practitioners is realized.

There are no data about workforce numbers or training needs specifically directed to prevention of mental disorders and substance abuse. One difficulty arises from the fact that prevention science and prevention implementation are not distinct disciplines, but are embedded in related disciplines, such as psychology, psychiatry, social sciences, social work, nursing, and medical specialties. Neuroscience, epidemiology and biostatistics, developmental sciences, and education could be added to this list. This positioning of prevention sciences and prevention implementation should be viewed as a strength, but it also creates difficulty in estimating both need and response.

The committee concurs with the 1994 IOM report that prevention training and education should be multidisciplinary, both for research and implementation, and should be layered on the professional skills acquired in traditional training programs. Trainees must be prepared not only to conduct prevention research in their own specialty area, but also to collaborate with colleagues in related areas. Therefore, there is a need to coordinate and integrate training across many disciplines and across a spectrum of prevention functions. The complexity of prevention efforts calls for broad and coordinated organization of training as well as multidisciplinary funding mechanisms.

Overview of Training/Education Since 1994

Since the 1994 IOM report, membership in the Society for Prevention Research increased 450 percent from 125 in 1992 to 690 in 2005 (see http://www.preventionresearch.org/about.php, accessed February 8, 2008). A search of the SPR online membership database identified 339 members who reported mental health as a content area, 434 who identified drugs, and 401 who identified alcohol.21 Other societies address specific areas in prevention research and program implementation (e.g., child abuse and neglect), but membership numbers do not capture those with a prevention orientation to MEB disorders.

One measure of training activity is the number of training grants awarded by NIH institutes for prevention training related to MEB disorders. Based on the committee’s analysis of FY 2006 training grants22 with either a major or minor focus on prevention:

  • The number of individual training grants, or F series (n = 13), was nearly the same as in 1994 (n = 12). These awards were relatively evenly dispersed across the three institutes (five each by NIMH and NIDA, three by NIAAA).
  • The number of institutional training grants (n = 29) grew substantially since 1994, when there were only five. Institutional prevention training grants addressing mental health were awarded to a variety of academic programs, including prevention science programs, schools of public health, and clinical psychology programs and departments of psychiatry, with a number mentioning opportunities for training across disciplines. NIMH funded a substantial majority of these institutional training awards (19 of 29). Nevertheless, institutional awards targeting some aspect of prevention made up less than 10 percent of all training awards from NIMH.
  • The largest number (n = 69) of training awards targeting prevention of MEB disorders consisted of career development grants (K series). The majority of these (n = 60) included a major focus on prevention of MEB disorders, often along with nonprevention objectives. These grants represent a substantial investment in career development by the three institutes, particularly NIMH, which funded 40 of the 69 awards. It is unclear whether young professionals who receive prevention training early in their faculty careers sustain this research support as they advance academically. Data concerning the rate of conversion of K series (career development) prevention awards to R (research) awards are not readily available.

The NIMH, NIDA, and NIAAA prevention research centers mentioned above, as well as the methodology centers discussed in Chapter 10, undoubtedly also fund infrastructural elements important for research training. For example, the NIMH prevention research center at Arizona State University provides a long-standing (20-year) model of training in prevention research. It prepares both predoctoral and postdoctoral trainees in four phases of prevention research: (1) generative research involving theoretical models of development, (2) design of interventions, (3) experimental field trials to test theoretical models, and (4) dissemination or diffusion of interventions to improve mental health and substance use outcomes through work in interdisciplinary teams (Sandler and Chassin, 2002). Training mechanisms include recent directions, such as quantitative methods, cross-cultural research, integrative models and multidisciplinary approaches, and longitudinal research. By 2002, the program had had 29 predoctoral and 22 postdoctoral trainees. Of the predoctoral trainees, 16 had finished their doctoral degree and 11 are in tenure-track faculty positions. Of the postdoctoral trainees, 12 are in tenure-track positions and 5 in research positions at medical schools and research centers (Sandler and Chassin, 2002).

In the past, NIMH funded up to 11 institutional training grants in the area of psychiatric epidemiology, a pivotal discipline for prevention program planning. However, these numbers have dwindled in the last several years, with five current programs.23

Needs for prevention research and implementation capacity building have not been formally assessed. Blueprint for Change: Research on Child and Adolescent Mental Health (National Advisory Mental Health Council Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment, 2001) called for greater research capacity to “take advantage of the promise of interdisciplinary research.” It recommended the creation of Child and Adolescent Interdisciplinary Training Institutes to include basic behavioral and neuroscience, epidemiology, prevention, intervention development, health services, and health economics research, as well as training in methodology, statistics, and the range of service settings in which mental health care is delivered. The report recommended a national mentorship program and suggested that NIMH explore opportunities to partner with MCHB, AHRQ of HRSA, CMHS/SAMHSA, and CSAP/SAMHSA to create and fund research training activities. As in many other reports, the emphasis of the blueprint was on treatment, not prevention. That report did note that, whereas overall NIMH funding, including K awards, had increased impressively over the preceding decade, the percentage of funds allocated to individual and institutional training grants, particularly those addressing child mental health, had not kept pace.

An example of a broadly positioned training program is Project Mainstream (Multi-Agency Initiative on Substance Abuse Training and Education for America), which is administered by AMERSA (Association for Medical Education and Research in Substance Abuse) and funded by HRSA and SAMHSA.24 The objectives of this project include the conduct of interdisciplinary faculty development programs and the creation of regional training networks as well as a national electronic communications resource to support faculty development in the area of substance abuse. This program has targeted training in 15 different health professions. The Project Mainstream strategic plan states that all graduating trainees should be competent in identifying and referring for assistance the children of parents with substance use disorders and advising communities about resources for effective substance use prevention programs, such as specialty-specific curricula and tools. Another goal of the strategic plan is to convene representatives of certification, accreditation, and licensure boards to consider how their organizations can contribute to substance use training through their requirements and testing processes. There is not a similar effort for multispecialty training in mental disorders identification, treatment, and prevention.

These data suggest that numbers of prevention science trainees have increased substantially since the 1994 IOM report. However, no conclusive statement can be made about the magnitude of growth in numbers of prevention scientists. It is likely that the numbers continue to fall short of needs and the opportunities to create, demonstrate efficacy of, and implement preventions that promise to reduce MEB disorders.

Current Training Efforts

Since 1994, when the focus of training was on prevention researchers, training and education needs have broadened. These now include other basic researchers who serve as discovery engines as well as a broad array of implementers and an informed citizenry (including public policy makers and funders).

Prevention Research

As in 1994, the majority of prevention scientists are psychologists (Eddy, Smith, et al., 2005). Eddy, Smith, and colleagues (2005) noted “a common inclination” in the field to assess interventions through randomized controlled trials while highlighting an additional approach labeled collaborative community action research. This approach broadens research to include assessment of implementation and also considers quasi-experimental designs as important contributors to prevention science knowledge (Eddy, Smith, et al., 2005).

To explore how these prescriptions for prevention science training have influenced current training, Eddy, Smith, and colleagues (2005) surveyed 262 self-identified prevention scientists across the spectrum of trainees, early investigators, and established researchers in 13 content areas. Areas with the least knowledge, training, and preparedness were new or developing ones (compared with traditional areas), particularly the history of prevention research, funding for prevention research, and the conduct of economic analyses. Early career participants were considerably behind established researchers in the areas of design of preventive intervention trials and community collaboration.

The results suggested that a “learning as you go” or apprentice model prevails and may not be rapidly responsive to the emergence of new content areas. Recommendations for training experiences included testing of various training models, cross-site training opportunities, participation in protocols that are in different phases of development and involve different methodologies, and embedding more prevention science in traditional graduate curricula. For training of postdoctoral scientists, opportunities to standardize curricula and expectations for training outcomes will be limited. Although several efforts have attempted to attract underserved minority trainees into prevention science, success in this area has been limited (Eddy, Martinez, et al., 2002). Such efforts are needed to improve the cultural competence and sensitivity of teams studying risk factors in these populations.

A specific identified need is midcareer training for scientists who wish to switch to the prevention research field (Sandler and Chassin, 2002). Training and funding mechanisms to support these career changes have not been systematically implemented and represent an important future opportunity.

Neuroscience

Neuroscience has exploded over the last decade or two, across multiple disciplines. There is no shortage of scientists being trained or in early career development stages in neurophysiology, neurogenetics, neurotoxicology, molecular neurosciences, and central nervous system imaging. A substantial number are focusing their efforts on understanding the biology of cognition, emotional responses, brain development, and psychopathology. It is very difficult, however, to identify the array of laboratories that are asking questions about neurobiological systems directly relevant to risk factors or protective factors or to interventions for early symptoms that herald MEB disorders.

Numerous laboratories are identifying genes associated with mental disorders as well as gene–environment interactions and epigenetic mechanisms (see Chapter 5). Predictive and preventive use of genetic information represents an attractive target for basic and translational research. Opportunities to train in these settings are abundant. Similarly, young investigators are training in imaging centers that are attempting to identify structural or functional variations in the brain that predict MEB disorders. The potential for these studies to facilitate prevention in the future is broadly accepted. Ensuring that biological and psychosocial approaches to prevention converge will be an important objective of training (see Chapter 5).

Public Health

A master of public health (M.P.H.) degree or a doctoral degree (Ph.D., Dr.Ph.) from a school of public health can be an initial step toward a career in prevention science. The published accreditation criteria for schools of public health (Council on Education for Public Health, 2005) list social and behavior sciences as one of five areas of knowledge basic to public health. Often this translates to study of behaviors that influence health-related decisions on a population basis. Prevention components of educational curricula and research programs more often target physical diseases. Some schools of public health do have curricula in mental health epidemiology and programmatically tie such disciplines as epidemiology, economics, and political science to preventive interventions in such content areas as alcohol or tobacco use, adult depression, and child psychopathology (Perry, Albee, et al., 1996). Related areas of training include behavioral science, mental health promotion, and health policy. Although data are not available to allow quantification of the contribution of schools of public health to the workforce related to prevention of MEB disorders, these schools should prepare future leaders in mental health promotion and disorder prevention, whether in research, community services, or administration/policy.

Health Care Professionals

The observation that “the health care workforce [is] . . . not equipped uniformly and sufficiently in terms of knowledge and skills, cultural diversity and understanding, geographic distribution, and numbers to provide the access to and quality of services needed by consumers” (Institute of Medicine, 2006b, pp. 286–324) was made with reference to mental health and certainly holds true for prevention, which has historically taken a back seat to diagnosis and treatment. Compounding this shortcoming is the broad range of health professionals who are engaged in mental health and substance use efforts, trained apart using curricula that are not built on core competencies or interdisciplinary considerations. The potential for clinicians to contribute systematically to prevention of MEB disorders is substantial, but realizing this potential will require transformational changes on the part of training institutions, professional societies, regulatory bodies, and funders.

Physicians: Medical School. Although health promotion and disease prevention are addressed formally or informally in many medical schools, mental health promotion and prevention of MEB disorders are often neglected. Less than half of all U.S. medical schools specifically address prevention and health maintenance. For those schools, it is taught primarily in the first 2 years for an average of only 22 hours (Institute of Medicine, 2004). Prevention of mental disorders would occupy at most a small percentage of that time. Similarly, dedicated training in substance use is rarely offered. According to 1998–1999 data from the Liaison Committee on Medical Education, only 8 percent of medical schools had a required course on substance use (Haack and Adger, 2002). The current level of exposure of medical students to substance use issues does not give graduates the confidence to screen, assess, or provide needed interventions (Miller, Sheppard, et al., 2001).

The knowledge base, skills, and attitudes for graduates regarding prevention of MEB disorders are not systemically assessed. The IOM report Improving Medical Education: Enhancing the Behavioral and Social Science Content of Medical School Curricula (2004, p. 98) recommended “that the National Board of Medical Examiners increase behavioral and social science content on the US Medical Licensing Examination.” Response to this recommendation would be a step in the right direction, but more specific attention to prevention and mental health promotion education is needed to prepare medical students for prevention activities related to MEB disorders.

Physicians: Residency. Postgraduate residency training in psychiatry; primary care specialties, such as pediatrics, internal medicine, and family medicine; preventive medicine; and in subspecialty training in such areas as behavioral and developmental pediatrics are particularly relevant to the prevention of MEB disorders among young people. However, there is no accredited pathway for subspecialty training of physicians in the prevention of MEB disorders.

Resident and subspecialty resident (fellow) experiences are dictated by the Accreditation Council for Graduate Medical Education (ACGME) program requirements and by the content specifications of the specialty and subspecialty certifying boards. Prevention research experiences for specialty and subspecialty residents are available to trainees, only if there are current research activities or interests in the environment in which they train.

Two programs of the Robert Wood Johnson Foundation have fostered prevention training: the highly competitive Clinical Scholars Program for postresidency training and the equally competitive Physician Faculty Scholars Program for assistant professors in an array of specialty areas. Both have funded scholars who have explored areas of prevention related to mental health. These programs are models for training that can attract future leaders to the area of prevention of MEB disorders.

ACGME requirements for psychiatry, pediatrics, and preventive medicine training pay little attention to prevention. For example:

  • Psychiatry training requirements state that the didactic curriculum must include the fundamental principles of epidemiology, etiology, diagnosis, treatment, and prevention of all psychiatric disorders, including biological, psychosocial, sociocultural, and iatrogenic factors that affect the prevention, incidence, prevalence, long-term course, and treatment of psychiatric disorders. They state that the resident should “know how to advocate for the promotion of mental health and the prevention of disease.” These are the only 2 sentences in 34 pages of requirements that directly address prevention of mental disorders and substance abuse; only eight hours on average are devoted to substance use health care in psychiatry residency (Isaacson, Fleming, et al., 2000).
  • Pediatric residents must be instructed, during a required one-month block in development and behavioral pediatrics, in psychosocial screening techniques as well as approaches to the identification of the needs of children at risk, for example, in fragmented or substance abusing families or in foster care. As a component of their one-month experience in adolescent medicine, residents are expected to engage psychosocial issues, such as depression, eating disorders, and substance abuse. No mention is made of prevention. Residents are expected to know how to advocate for promotion of health and prevention of disease or injury, but with no specification of applications to behavioral disorders. Subspecialty residents in pediatrics are not formally trained to recognize chronic health disorders as risk factors for MEB disorders of youth.
  • Requirements for training in preventive medicine25 are largely silent with regard to prevention of MEB disorders. Core knowledge is expected to include “behavioral aspects of health,” but the requirements do not otherwise address MEB disorders or their prevention. The certifying examination for preventive medicine does not specifically test knowledge or skills directed to prevention of MEB disorders. Drug use training in preventive medicine residency largely focuses on tobacco (Abrams, Saitz, and Sancet, 2003).

None of the medical specialty training requirements emphasize the need to be conversant with screening for risk or protective factors for mental disorders or to understand systems that are in place to manage risk as well as reinforce protective factors. The overall lack of attention to training related to prevention of MEB disorders contrasts with a consensus in the pediatric community that training for residents should be enhanced to prepare them for more knowledgeable, competent behavioral/mental health screening and care (American Academy of Pediatrics, 2001; American Academy of Pediatrics Task Force on Mental Health, in preparation). The American Board of Family Medicine (ABFM) has identified similar needs for their trainees (personal communication with Larry Green, ABFM board member, October 8, 2007).

Social Work

Master’s-level social work training (the routine degree for practitioners) currently is provided by approximately 200 programs accredited by the Council on Social Work Education. Accreditation standards do not address substance use in general or prevention in this realm (Straussner and Senreich, 2002). Curriculum requirements emphasize content in human behavior, clinical diagnosis, treatment planning, and service delivery. Prevention frameworks and program examples are included in the Human Behavior and Social Environment course sequences required of all social work graduate curricula. While a 1996 report (Perry, Albee, et al., 1996) found that only 12 schools offered a course in prevention (not specifically prevention of MEB disorders), most schools of social work have elective courses in drug and alcohol abuse prevention, and many offer courses in mental health interventions, as well as child maltreatment prevention and treatment.

Since 1993, NIMH has funded a small number of social work programs to conduct research as well as provide special scholarships and coursework on prevention research for doctoral students, which has increased the supply of researchers trained in prevention research methods (Institute for the Advancement of Social Work Research, n.d.). Recently, NIMH launched other initiatives to enhance partnerships to integrate evidence-based mental health practices into social work education and research (Institute for the Advancement of Social Work Research, n.d.), but prevention research is a relatively small part of these initiatives.

Clinical Psychology. There are approximately 90,000 clinically trained psychologists in the United States, many of whom have training in child psychology. Training in prevention of MEB disorders is not standard for most master’s- or doctoral-level curricula or for certification or licensure in school psychology. A 2003 report of a task force of the Society of Pediatric Psychology recommended 12 topic areas most important for training experiences of child psychologists. Three of these areas were prevention, family support, and health promotion (Spirito, Brown, et al., 2003). Similarly, in their call for redesign of clinical psychology graduate education, Snyder and Elliott make a case for focus on individual strengths (protective factors), and lifestyle or community-level influences on mental health. They conclude that prevention must be an essential feature of education curricula. They note that a few psychology training programs do stress reduction of risk factors, but they recommend that postdoctoral programs in clinical psychology increase their focus on prevention and health (Snyder and Elliott, 2005). The response to these recommendations will be important to monitor.

Similarly, psychologists typically receive little training or preparation for dealing with substance abuse. Half or more receive no didactic or practical training in substance use conditions according to a 1990s survey (Institute of Medicine, 2006b). Their clinical training, as for other health professionals, is focused on diagnosis and treatment. Certification of clinical competence is offered by the American Board of Professional Psychology. Licensure in some states requires written or oral evaluations of knowledge. Neither licensure nor certification assesses competence related to prevention of MEB disorders.

Community psychology, developmental psychology, and social psychology are other potential training pathways for a career in prevention research and program implementation, although none of these areas focuses exclusively or in major part on prevention. It is not uncommon for graduate students who wish to work in the area of prevention of MEB disorders to construct independent study programs (Perry, Albee, et al., 1996).

Nursing. Nursing education is generally completed in two (associate’s degree) or four years (bachelor’s degree; eligibility for licensure as a registered nurse). Increasing numbers of nursing students become nurse practitioners with advanced degrees, either a master’s or a doctor of nursing practice. A number of nursing students are obtaining Ph.D.s, acquiring nursing research skills, and working in academic or research settings. Nursing school curricula stress prevention concepts, but most devote little time to prevention of MEB disorders. One effort has been the Nursing Child Assessment Satellite Training at the University of Washington, a national program to train nurses and other health care professionals to assess parent–child relationships in community settings.26 Psychiatric nurses (more than 18,000; Institute of Medicine, 2006b) usually have added training or a graduate degree and are certified by the American Nurses Credentialing Center. There are more than 20 university-based master’s degree programs in psychiatric nursing, many having specialty tracks specific to child and adolescent psychiatric nursing, and a certification process for child/adolescent psychiatric nursing. As with other health care professions, advanced training does not uniformly target prevention. However, there are innovative efforts, such as a 2008 HRSA award to the College of Nursing at Arizona State University for the multidisciplinary online training program called KySS (Keep Your Child/Yourself Safe, and Secure), focused on screening, identifying, and delivering evidence-based intervention for youth experiencing common MEB problems.27 Prevention training related to MEB disorders in nursing is an important opportunity.

Substance Abuse and Mental Health Counseling. Substance abuse counselors and mental health counselors together comprise the largest group of mental health professionals. Numbers of mental health counselors alone approach 120,000, and half of the personnel delivering substance use treatment are substance abuse counselors (Institute of Medicine, 2006b). Coursework and practical experience requirements vary between these two groups, across state lines, and from program to program. Licensure or certification is required by some states, more for mental health than for substance abuse counselors. Requirements for coursework or practicum experience, when they are specified, do not include exposure or experience related to preventive aspects of MEB disorders (Kerwin, Walker-Smith, and Kirby, 2006). The content of continuing education is largely unspecified and does not require that preventive aspects of MEB disorders be addressed. While many states have certified preventionist positions in the area of substance abuse prevention, with criteria for certification specified, no comparable position exists in the mental health area.

Education Providers

Neither the core curriculum for a bachelor’s degree nor the process for obtaining a teaching certificate anticipate that teachers will be prepared to recognize risk factors or detect early evidence of MEB disorders in their pupils. Coursework for education degree students includes descriptions of mental disorders (along with physical disorders and retardation), but it does not systematically include how to identify, intervene, or refer children at risk for MEB disorders. Special education trains teachers to recognize and work with children who have special needs that schools, by law, must address. Children with externalizing disorders (conduct, hyperactivity) are identified and directed to remedial programs when they are disruptive. Children with internalizing disorders (e.g., withdrawal, anxiety, depression) are often not identified for attention because they do not impose an added burden on the teacher or classroom. As federal mandates for testing and academic achievement have been strengthened, MEB issues have been relegated to lower priority status for teachers. Training in evidence-based behavior management techniques for teachers is essential for helping them to address the behavior problems that can develop into MEB disorders (Epstein, Atkins, et al., 2008).

The National Association of School Psychologists has 25,000 members and strongly encourages mental health promotion and prevention of disorders through a variety of programs. For example, Prevention, Crisis Intervention and Mental Health is 1 of 11 domains of the organization’s continuing professional development program (NASP Professional Development; see http://www.nasponline.org, accessed September 29, 2008). However, the contribution of school psychologists has limitations as a result of school budget contractions. Except for a few schools that have adopted specific experimental or innovative universal or selective interventions, most schools do not prepare their staff to screen for risk factors, nor do they adopt universal measures to decrease risk or enhance protective factors (personal communication, Mary Boat, College of Education, University of Cincinnati). In many ways, this is an opportunity lost, but transformational changes will be needed in school systems to respond to this opportunity. Nevertheless, the school setting represents one of the best opportunities for prevention interventions, whether universal, selective, or indicated.

Preschools and day care centers (for children from birth to age 5) may be in the most advantageous position to observe young children and identify risks or early symptoms. However, preschool teachers often have less training than school teachers and are frequently unprepared to engage in activities that lead to identification and helpful intervention for mental, emotional, and behavioral problems.

Law and the Judicial System

While some individuals in the legal system appear to be aware and responsive to the needs of children, particularly those at risk for MEB disorders, children’s needs are often secondary to other considerations. Such situations arise frequently when such issues as child custody and visitation are decided in cases of divorce, domestic violence, or child abuse and neglect. Recognition that these situations place children’s mental health at risk should lead to decisions that consider, above all, the children’s well-being. Enhanced mechanisms for informing lawyers, magistrates, and judges about the role they can play in the prevention of MEB disorders should be adopted, starting in law school.

Public Awareness and Public Policy

A pivotal effort must target the training of youth, their families, and the public to understand the importance of mitigating risks for MEB disorders. This universal approach should include policy makers and individuals who determine how public and private funds will be allocated in the attempt to improve mental health outcomes for children.

A public that is aware of the huge burden of MEB disorders, as well as the needs and opportunities for prevention, will be more likely to promote informed decision making about programmatic responses from both the private and the public sectors. Vehicles for dissemination of information include, first and foremost, the media, including opportunities to dispel the stigma associated with MEB disorders (see Chapter 8). Schools should also play a role, as should primary health care providers. Professional societies, as well as private and government agencies, should have major educational roles. Priorities have targeted diagnosis, treatment, and rehabilitation, perhaps at the expense of prevention efforts. Achieving the proper balance in the future will require informed discussions and decisions at the highest levels. Prevention often is not addressed because the public expects immediate return on its investment. Education should include compelling information about the real and potential benefits and cost reductions of successful prevention efforts. In particular, this information should be directed to public policy makers. Education and possibly publicly supported incentives must also target health care payers who currently often refuse reimbursement for prevention efforts.

CONCLUSIONS AND RECOMMENDATIONS

For the goals of prevention of MEB disorders to be achieved, the three elements of prevention program infrastructure in this chapter must be the focus of ongoing improvement efforts: innovation driven by funded research, a coordinated and effective delivery system, and enhancement of workforce quality and quantity.

Developing a Coordinated and Effective Delivery System

Numerous federal programs and resources fund and guide states and communities in their promotion and prevention efforts. Coordination across these efforts is limited and presents a barrier to large-scale implementation of best practices. Funding for programs and their evaluation is fragmented and inadequate to reach many youth in need. As communities increasingly are able to select programs from available lists of evidence-based approaches, the infrastructure to sort out how best to match program features with community needs and resources and to learn what constitutes the most effective match is often not in place.

Conclusion: Federal programs whose goals include the prevention of MEB disorders are not well coordinated, and there is little strategic synergy between research and service delivery.

Compounding the deficiencies of infrastructure are substantial barriers to implementation of prevention programs in potentially advantageous settings, such as day care, schools, and primary medical care. Too often programs are created de novo and require costly new infrastructure. Barriers such as funding or reimbursement of services can be addressed most effectively at a national or state level. Program funding often does not include expectations that demonstrably effective programs be implemented with fidelity or that outcomes of these programs be rigorously evaluated, and it does not typically support outcomes assessments.

Conclusion: There is a need for the development of systems (service sites and networks) that can implement evidence-based programs, test their effectiveness in real-world environments, and provide a funding stream for evidence-based prevention services.

Funding and infrastructure for substance abuse prevention interventions is more advanced than for prevention or promotion of mental health. There are no targeted funding streams for prevention in the mental health area.

Recommendation 12-1: Congress should establish a set-aside for prevention services and innovation in the Community Mental Health Services Block Grant, similar to the set-aside in the Substance Abuse Prevention and Treatment Block Grant.

Providing a set-aside with the Mental Health Services Block Grant could send a clear message that prevention is a priority and begin to help refocus the mental health system on prevention activities. This should be the first step in refocusing the mental health system to include a targeted focus on prevention and should be coupled with efforts across agencies to increase prevention funding, including collaborations between SAMHSA and the Centers for Medicaid and Medicare Services to address barriers to reimbursement of prevention services. At the same time, innovation in other service systems is also needed, ideally coupled with rigorous evaluation to continue to develop prevention systems. Resources for preventive services, however, often do not include sufficient evaluation resources.

Recommendation 12-2: The U.S. Departments of Health and Human Services, Education, and Justice should braid funding of research and practice so that the impact of programs and practices that are being funded by service agencies (e.g., the Substance Abuse and Mental Health Services Administration, the Office of Safe and Drug-Free Schools, the Office of Juvenile Justice and Delinquency Prevention) are experimentally evaluated through research funded by other agencies (e.g., the National Institutes of Health, the Institute of Education Sciences, the National Institute of Justice). This should include developing appropriate infrastructure through which evidence-based programs and practices can be delivered.

Models for implementing braided funding, which is supported by NIMH’s Bridging Science and Services report (National Institute of Mental Health, 2006), could include joint requests for proposals or targeting research resources to existing service programs. One example of the latter approach is a recent request for applications from NIH that targeted research resources for research activities tied to grantees under SAMHSA’s Comprehensive Community Mental Health Services Program for Children and Families.28 Other federal programs, such as initiatives under SAMHSA’s Strategic Prevention Framework, including the SSHS Program, could be similarly linked with NIH research resources.

Numerous preventive interventions are now available and being implemented by states and communities. However, efforts to expand these interventions state-, county-, or locality-wide are needed to establish an infrastructure for the delivery of preventive interventions across systems of care.

Recommendation 12-3: The U.S. Departments of Health and Human Services, Education, and Justice should fund states, counties, and local communities to implement and continuously improve evidence-based approaches to mental health promotion and prevention of MEB disorders in systems of care that work with young people and their families.

A dizzying array of technical assistance centers, online resources, and publications and guides is available. Prominent among them are efforts to identify effective programs. Differences across these efforts, particularly in the standards applied, make it difficult to understand the meaning of an assigned rating or to assess the expected results of a given program.

Recommendation 12-4: Federal and state agencies should prioritize the use of evidence-based programs and promote the rigorous evaluation of prevention and promotion programs in a variety of settings in order to increase the knowledge base of what works, for whom, and under what conditions. The definition of evidence-based should be determined by applying established scientific criteria.

In applying scientific criteria, the agencies should consider the following standards:

  • Evidence for efficacy or effectiveness of prevention and promotion programs should be based on designs that provide significant con-fidence in the results. The highest level of confidence is provided by multiple, well-conducted randomized experimental trials, and their combined inferences should be used in most cases. Single trials that randomize individuals, places (e.g., schools), or time (e.g., wait-list or some time-series designs) can all contribute to this type of strong evidence for examining intervention impact.
  • When evaluations with such experimental designs are not available, evidence for efficacy or effectiveness cannot be considered definitive, even if based on the next strongest designs, including those with at least one matched comparison. Designs that have no control group (e.g., pre-post comparisons) are even weaker.
  • Programs that have widespread community support as meeting community needs should be subject to experimental evaluations before being considered evidence-based.
  • Priority should be given to programs with evidence of effectiveness in real-world environments, reasonable cost, and manuals or other materials available to guide implementation with a high level of fidelity.

Also key to these efforts will be education of the public about the need for prevention efforts and the benefits that can be achieved. An informed and supportive public is needed to adopt and advocate for effective prevention of MEB disorders and promotion of better mental health outcomes.

Research

Although the volume of prevention research and evidence for successful intervention efforts has grown substantially since 1994, there are rapidly expanding needs for more and better research. In contrast to the need and opportunity, funding for studies of preventive interventions for MEB disorders and their implementation has taken a back seat to funding of studies directed to the diagnosis and treatment of behavioral disorders. In addition, no single agency (federal or private) has prioritized research funding directed to the prevention of MEB disorders or is driving prevention research efforts in a coordinated way.

Conclusion: Federal agencies responsible for funding mental health research have prioritized studies of treatment over prevention.

Several NIH institutes (NIMH, NICHD, NIDA, NIAAA, AHRQ) contribute substantially but focus largely on a single disorder. Coordinated funding by NIH institutes and other agencies is not visible. This paucity of prospective, collaborative funding makes it particularly difficult to generate an integrated, comprehensive approach to innovative prevention research. Funding mechanisms for stimulating research at the intersection of basic science and the development and implementation of new and better preventive interventions are needed now and will be increasingly critical in the future. Basic research in neurobiology, psychology, sociology, economics, and related fields should be supported to fuel the creation of novel strategies for prevention and to promote collaborative, multidisciplinary translational research to document the effectiveness of these strategies (see also Recommendations 5-2 and 5-3).

Recommendation 12-5: The National Institutes of Health and other federal agencies should increase funding for research on prevention and promotion strategies that reduce multiple MEB disorders and that strengthen accomplishment of age-appropriate developmental tasks. High priority should be given to increasing collaboration and joint funding across institutes and across federal agencies that are responsible for separate but developmentally related outcomes (e.g., mental health, substance use, school success, contact with the justice system).

To date there is relatively little cofunding of prevention research across NIH institutes. Such efforts may be discouraged if each institute is not given sufficient recognition of its support on a cofunded grant. Given the importance of looking at comprehensive outcomes that are the purview of specific institutes and the current fiscal limitations for NIH research, it may be necessary to offer additional incentives for institutes to cofund important prevention research. The new policy at NIH that acknowledges the important contributions of multiple investigators is a model that could also be used at the institute level to acknowledge the contributions of multiple agencies providing cofunding.

Training

Training in prevention research, whether basic, epidemiological, translational, or implementation, is not responsive to ongoing opportunity or needs. Workforce numbers remain insufficient to carry out research and service programs targeted to prevention of MEB disorders. The complexity of prevention efforts calls for more coordinated training in multidisciplinary settings. More and better investigators are needed in all areas, particularly in the field of implementation sciences. Recruitment of future leaders should be enhanced by attracting the most talented young investigators to prevention research, through NIH-supported multidisciplinary training programs. As discussed in Chapter 5, coordination among researchers from diverse disciplines, such as developmental neuroscience, developmental psychopathology and prevention science, as well as collaboration across institutions are needed to integrate expanding knowledge from these fields.

Prevention training is neglected for a broad array of health professionals (doctors, nurses, psychologists, social workers) and for teachers as well as other school personnel, for whom prevention should be a priority issue. When mental health or substance abuse is included in a training curriculum, it tends to focus on diagnosis and treatment. Similarly, prevention and promotion content tends to emphasize general health over mental health concerns. Refinement and broad implementation of prevention interventions are likely to languish unless more extensive and robust training is realized.

Conclusion: Most training programs in major disciplines, such as medicine, education, psychology, social work, and public health, do not include core components on the prevention of MEB disorders of young people, including how to identify and manage the risks and preclinical symptoms of these disorders.

Recommendation 12-6: Training programs for relevant health (including mental health), education, and social work professionals should include prevention of MEB disorders and promotion of mental, emotional, and behavioral health. National certifying and accrediting bodies for training should set relevant standards using available evidence on identifying and managing risks and preclinical symptoms of MEB disorders.

Recommendation 12-7: The U.S. Departments of Health and Human Services, Education, and Justice should convene a national conference on training in prevention and promotion to (1) set guidelines for model prevention research and practice training programs and (2) contribute to the development of training standards for certifying and accrediting training programs in specific disciplines, such as health (including mental health), education, and social work.

Recommendation 12-8: Once guidelines have been developed, the U.S. Departments of Health and Human Services, Education, and Justice should set aside funds for competitive prevention training grants to support development and dissemination of model interdisciplinary training programs. Training should span creation, implementation, and evaluation of effective preventive approaches.

Training models should be applied in both research contexts involving multiple disciplines and multidisciplinary approaches to training providers that work with young people.

Footnotes

1

Funding information was available for 261 of the 424 (62 percent) published randomized controlled trials identified. The Public Health Service, which includes NIH and all of the health agencies within HHS, was the primary source.

2
3
4

NIDA was not able to provide an accounting of treatment research.

5

NIMH and NIDA each also fund a center that addresses prevention methodology (see Chapter 9).

6

At the time the information was submitted by NIMH and NIDA, FY 2006 was the most recent year for which complete data were available. NIAAA, which submitted information later, provided data for FY 2007. NIMH grants provided to the committee included those that are coded in their database as targeting ages 0–25. It did not provide grants coded as “age unspecified,” which may include some grants funded by NIMH that target this population.

7

Abstracts classified by NIMH as prevention of negative sequelae were included, but only projects considered by the committee to be prevention were included in this analysis. The coding was refined through a pilot phase involving multiple reviewers, with final coding conducted by two independent reviewers. Where the two reviewers did not agree on a code, a consensus was reached in consultation with a third coder. This was needed most often for the intervention type (24 percent of the abstracts) and trial type (38 percent of the abstracts).

8

This appendix is available online only. Go to http://www​.nap.edu and search for Preventing Mental, Emotional, and Behavioral Disorders Among Young People.

9

The Child Mental Health Foundations and Agencies Network, a group of public and private agencies and foundations interested in issues of child development and public policy, aims to improve connections between research, practice, and policy. A request was submitted to its members for information on relevant activities, but none was received in time for consideration in this report.

10

The Office of Safe and Drug-Free Schools administers several programs with preventive goals, including the Healthy Student Initiative, Governors’ Grants, Grants to States to Improve Management of Drug and Violence Prevention Programs, State Grants, Prevention Models on College Campuses, Grants for School-based Student Drug Testing, Grants to Reduce Alcohol Abuse, and Grants to Prevent High-risk Drinking and Violent Behavior Among College Students (U.S. Department of Education).

11

These funds would support efforts surrounding suicide prevention, stigma and discrimination reduction, ethnic and cultural disparity reduction, training and capacity building, evaluation, and student mental health.

12
13

NREPP began as the Model Programs initiative in the Center for Substance Abuse Prevention.

14

NREPP does not include a category for prevention of mental disorders, so mental health promotion in this context combines the terms as used by the committee.

15

NREPP’s predecessor, Model Programs, identified 66 model and 37 effective programs (many of which are prevention programs). All of these programs had to re-reviewed to be included in NREPP.

16
17

The program is being re-reviewed by NREPP, but it is unclear if this study will be included in the review.

18
19
20
21

Members can report more than one content area.

22

Abstracts of all FY 2006 grants listed in the NIH CRISP database were evaluated for proposed prevention-related research training and career development.

23
24
25

Preventive medicine is a three-year training program for physicians that combines a year of clinical medicine and 24 months of academic and practicum training, leading to an M.P.H.

26
27
28
Image ch1f1-1
Copyright © 2009, National Academy of Sciences.
Bookshelf ID: NBK32774

Views

  • PubReader
  • Print View
  • Cite this Page
  • PDF version of this title (3.5M)
  • Disable Glossary Links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...