There have been many areas of progress in preventive intervention research since the 1994 Institute of Medicine (IOM) report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. The volume, reliability, and richness of experimental research have significantly improved in part because of significant advances in the methodological approaches applied to intervention research. Randomized trials, which were strongly recommended in the 1994 IOM report, have expanded (see Figure 1-1). Research has identified beneficial preventive interventions throughout young people’s development and for a range of outcomes. As the body of intervention research has increased, the number of studies that include economic analyses to explore the costs and benefits of these interventions has also increased, further supporting the value of these approaches. This makes a case for supplementing traditional universal health care approaches, such as prenatal care, immunizations, and policies that support families, to support the healthy development of young people.

This report cannot cover the hundreds of randomized controlled trials that have been conducted since the 1994 IOM report. Instead, the analysis cites and draws on the findings of the several dozen relevant meta-analyses and systematic reviews, which themselves are testimony to the substantial increase in relevant research. The analysis also highlights specific interventions that have been tested and refined in several well-designed randomized controlled trials; some include analyses of cost-effectiveness or long-term outcomes. Although this does not include the many interventions for which some evidence is available, or even all that have been labeled by other groups as effective, it does focus on interventions that have been most rigorously evaluated and illustrates the potential to prevent numerous mental, emotional, and behavioral (MEB) disorders and the problem behaviors related to them. Box II-1 highlights some of the major outcomes of these interventions. In some areas in which evidence is more limited but there is clear conceptual potential, we mention interventions that appear promising but have not been tested in multiple experimental evaluations.

BOX II-1

Outcome Highlights of Preventive Interventions. Prevention of Child Maltreatment Meta-analyses have found that interventions that promote family wellness and provide family support are successful in preventing child maltreatment.

The prevention science field draws a valuable distinction between efficacy trials, which demonstrate results in a research environment, and effectiveness trials, which demonstrate results in a real-world environment. Although efficacy trials can be helpful in validating the conceptual basis for an intervention, the findings of effectiveness trials are viewed as being more relevant to community settings and the interventions as they will be implemented in everyday practice. The tide has begun to turn, with effectiveness trials beginning to emerge.

As discussed in Part I, young people develop in the context of their families, schools, and communities. Interventions designed to support healthy emotional and behavioral development and prevent disorder take place largely in the contexts of these support systems. Such interventions as prenatal care, home visiting, parenting skills training, programs designed to mitigate specific family-based strain (e.g., bereavement, dealing with a mentally ill parent), and some public policies share a goal of improving family functioning and creating nurturing environments. Many other interventions aimed at a range of problem behaviors have been developed to reach young people through schools, and community-wide approaches have begun to emerge. Some interventions combine aspects of family-based interventions with school-based approaches. These family, school, and community-wide approaches are discussed in Chapter 6.

Chapter 7 includes a discussion of preventive interventions that are targeted at specific disorders rather than at specific settings. Delivered in mental health, health, and school settings, these interventions deal directly with children, with parents, and with the whole family. Chapter 7 also includes interventions targeted at mental health promotion, including intervention strategies related to modifiable lifestyle factors.

The range of developmental phases in a young person’s life offers variable opportunities for intervention. Interventions are designed to address differential risk and protective factors prominent in a particular developmental stage or the emergence of symptoms that tend to occur at different ages. Most of the interventions discussed in Chapters 6 and 7, regardless of their mechanism, target young people during one or more developmental phases (see Figure II-1).

FIGURE II-1

Interventions and their targeted developmental stages.

Preventive interventions are characterized by the level of risk of the population targeted for intervention. Screening, typically thought of in the context of indicated preventive interventions, in which individuals demonstrate elevated symptom levels that precede a diagnosis of disorder, may have applications for universal and selective interventions as well. The nation should proceed with caution, however. These issues are discussed in Chapter 8.

Family-, school-, and community-based interventions can help reduce the significant personal, family, and social costs of MEB disorders and related problem behaviors. These costs and available economic analyses of some of the interventions discussed in Chapters 6 and 7 are outlined in Chapter 9.

Finally, significant methodological advances since 1994 have increased the reliability of causal inferences possible from preventive intervention research and provided the field with solid guidelines on the design and conduct of quality research. These developments are discussed in Chapter 9, which also provides a bridge to Part III, New Frontiers, by outlining some of the methodological challenges and opportunities for the next generation of prevention research.

The evidence presented here has important practical implications for the practices of the schools, family service agencies, and health care providers that are involved at each stage of the development of young people. Taken together, the evidence shows that the nation could support the healthy development of many more young people.

6. Family, School, and Community Interventions

7. Prevention of Specific Disorders and Promotion of Mental Health

8. Screening for Prevention

9. Benefits and Costs of Prevention

10. Advances in Prevention Methodology