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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.

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

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Summary

Several decades of research have shown that the promise and potential lifetime benefits of preventing mental, emotional, and behavioral (MEB) disorders are greatest by focusing on young people and that early interventions can be effective in delaying or preventing the onset of such disorders. National priorities that build on this evidence base should include (1) assurance that individuals who are at risk receive the best available evidence-based interventions prior to the onset of a disorder and (2) the promotion of positive MEB development for all children, youth, and young adults.

A number of promotion and prevention programs are now available that should be considered for broad implementation. Although individuals who are already affected by a MEB disorder should receive the best evidence-based treatment available, interventions before the disorder occurs offer the greatest opportunity to avoid the substantial costs to individuals, families, and society that these disorders entail.

Most MEB disorders have their roots in childhood and youth. Among adults reporting a MEB disorder during their lifetime, more than half report the onset as occurring in childhood or adolescence. In any given year, the percentage of young people with these disorders is estimated to be between 14 and 20 percent. MEB issues among young people—including both diagnosable disorders and other problem behaviors, such as early drug or alcohol use, antisocial or aggressive behavior, and violence—have enormous personal, family, and societal costs. The annual quantifiable cost of such disorders among young people was estimated in 2007 to be $247 billion. In addition, MEB disorders among young people interfere with their ability to accomplish normal developmental tasks, such as establishing healthy interpersonal relationships, succeeding in school, and transitioning to the workforce. These disorders also affect the lives of their family members.

A 1994 report by the Institute of Medicine (IOM), Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, highlighted the promise of prevention. In response to a subsequently burgeoning research base and an increasing understanding of the developmental pathways that lead to MEB problems, the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism requested a study from the National Academies to review the research base and program experience since that time, focusing on young people. The Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults was formed under the auspices of the Board on Children, Youth, and Families to conduct this review (see Box S-1 for the complete charge).

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BOX S-1

Committee Charge. Review promising areas of research that contribute to the prevention of mental disorders, substance abuse, and problem behaviors among children, youth, and young adults (to age 25), focusing in particular on genetics, neurobiology, and (more...)

The 1994 IOM report reaffirmed a clear distinction between prevention and treatment. The current committee supports this distinction. The prevention of disability, relapse, or comorbidity among those with currently existing disorders are characteristics and expectations of good treatment. Although treatment has preventive aspects, it is still treatment, not prevention. The strength of prevention research using this concept of prevention, coupled with the need for focused research on risks prior to the onset of illness, warrants the field’s continued use of a typology focused on interventions for those who do not have an existing disorder. Interventions classified as universal (population-based), selective (directed to at-risk groups or individuals), or indicated (targeting individuals with biological markers, early symptoms, or problematic behaviors predicting a high level of risk) are important complementary elements of prevention. Going beyond the 1994 IOM report, we strongly recommend the inclusion of mental health promotion in the spectrum of mental health interventions.

The volume and quality of research since 1994 have increased dramatically. Clear evidence is available to identify many factors that place certain young people or groups of young people at greater risk for developing MEB disorders, as well as other factors that serve a protective role. Box S-2 summarizes key advances since 1994.

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BOX S-2

Key Areas of Progress Since 1994. Evidence that MEB disorders are common and begin early in life. Evidence that the greatest prevention opportunity is among young people.

A number of specific preventive interventions can modify risk and promote protective factors that are linked to important determinants of mental, emotional, and behavioral health, especially in such areas as family functioning, early childhood experiences, and social skills. Interventions are also available to reduce the incidence of common disorders or problem behaviors, such as depression, substance use, and conduct disorder. Some interventions reduce multiple disorders and problem behaviors as well as increase healthy functioning. While the evidence on the costs and benefits of interventions is limited, it suggests that many are likely to have benefits that exceed costs.

In addition, a number of interventions have demonstrated efficacy to reduce risk for children exposed to serious adversities, such as maternal depression and family disruption. Like family adversities, poverty is a powerful risk factor, and its reduction would have far-reaching effects for multiple negative mental, emotional, and behavioral outcomes. Numerous policies and programs target poverty as a risk factor by giving priority to low-income children and their families and by promoting resources for healthy functioning of those living in poverty through, for example, early childhood education programs, programs to strengthen families and schools, and efforts to reduce neighborhood violence.

The 1994 IOM report expressed hope that identification of the genetic determinants of mental illnesses was on the horizon. It is now recognized that most disorders are not caused by a small number of genes and that this area of research is highly complex. An emerging area of research involves the influence of the environment on the expression of a specific gene or set of genes, the importance of epigenetic modification of gene expression by experience, and direct injury to neural systems that give rise to illness. This exciting new knowledge has the potential to inform future preventive interventions.

The future of prevention requires combined efforts to (1) apply existing knowledge in ways that are meaningful to families and communities and (2) pursue a rigorous research agenda that is aimed at improving both the quality and implementation of interventions across diverse communities.

PUTTING KNOWLEDGE INTO PRACTICE

No concerted federal presence or clear national leadership currently exists to advance the use of prevention and promotion approaches to benefit the mental health of the nation’s young people. Infusing a prevention focus into the public consciousness requires development of a shared public vision and attention at a higher national level than currently exists.

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

Mental, emotional, and behavioral disorders among young people burden not only traditional mental health and substance abuse programs, but also multiple other service systems that support young people and their families—most notably the education, child welfare, primary medical care, and juvenile justice systems. According to one estimate, more than a quarter of total service costs for children who have these disorders are incurred in the school and juvenile justice systems. Similarly, a quarter of pediatric primary care visits address behavioral issues. The cost savings of prevention programs likewise are experienced in a range of service systems. A national-level response therefore requires the creation of a designated entity with the authority to establish common prevention goals, to direct relevant federal resources, and to influence the investment of state, local, or private resources toward these goals as well as coordination and leadership across and within multiple federal agencies.

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

Federal resources should support the continued evaluation and refinement of programs to increase understanding of what works for whom and when. The braiding of programmatic funding from service agencies, such as the Substance Abuse and Mental Health Services Administration, with evaluation funding from research agencies, such as the National Institute of Mental Health, would advance these efforts. Establishment of an ongoing national monitoring system that is capable of regular reporting on the incidence and prevalence of specific disorders, as well as the rates of exposure to key risk and protective factors, is needed to assess performance compared with national goals.

Determining what is “evidence-based” is an important component of ensuring that these efforts have a positive impact on the lives of young people. Priority should be given to programs that have been tested and replicated in real-world environments, that have reasonable cost, and that are supported by tools that will help to implement key elements of the programs with fidelity. Federal and state agencies should not endorse programs that lack empirical evidence solely on the basis of general community endorsement. In turn, states and communities need to consider the relevance of available models to their own needs, priorities, and cultural contexts. They should evaluate programs and systems that they adopt, so as to continue to build the prevention knowledge base. Programs should also engage in and document the results of quality improvement efforts to continuously enhance program outcomes.

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

Concurrently, concerted attention should be paid to developing a work-force that has the knowledge base and skill sets necessary to research, implement, and disseminate relevant interventions in diverse community contexts and cultures. Training and certification programs for the next generation of professionals working with young people should include the latest knowledge of the early trajectories of disorders and of prevention approaches in a life-course framework. Box S-3 provides a list of other specific recommendations relevant to putting knowledge into practice.

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BOX S-3

Recommendations: Putting Knowledge into Practice. Funding and Implementation 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 (more...)

CONTINUING A COURSE OF RIGOROUS RESEARCH

The National Institutes of Health (NIH) fund research related to the prevention of MEB disorders through multiple centers and institutes. A significant body of research now points to common trajectories across multiple disorders and highlights the potential for interventions to affect multiple disorders. However, no definition of prevention is shared across agencies, no NIH-wide planning or accounting of prevention spending exists, and there are no common research priorities. In addition, most NIH research centers address single disorders. The ability of prevention research to approach issues from a comprehensive developmental perspective would be aided by cross-institute dialogue and by coordinated funding for interventions that address co-occurring outcomes, common risk and protective factors, and shared developmental pathways.

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

Continued investment in research can lead to interventions that will mitigate risks and strengthen protective factors prior to the onset of disorders and that will help to set young people on an appropriate developmental course. Substantial evidence has shown that the incidence of many disorders and problem behaviors can be reduced significantly, thereby justifying the need for dedicated efforts to refine these approaches.

Recommendation: Research funders1 should establish parity between research on preventive interventions and treatment interventions. (13-4)

The report makes a number of specific recommendations aimed at identifying areas of focus for future research in a 10-year plan that will inform future federal, state, and local initiatives (see Box S-4). The following focus areas should serve as the research priorities for both federal agencies and foundations, and they should stimulate prevention partnerships:

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BOX S-4

Recommendations: Continuing a Course of Rigorous Research. Overall Research funders* should fund preventive intervention research on (1) risk and protective factors for specific disorders; (2) risk and protective factors that lead to multiple mental, (more...)

  • Approaches to screening in conjunction with intervention. Screening can take place at multiple levels, including the level of the population to identify communities at risk (e.g., high-poverty neighborhoods), the level of groups to identify those at risk (e.g., children with depressed parents), and the level of individuals to identify those who have either behavioral symptoms or biological markers indicating the likelihood of developing a disorder (e.g., young children who exhibit highly aggressive behavior). However, screening without community acceptance and sufficient service capacity to respond to identified needs is of limited value. Models are needed that partner screening with implementation of evidence-based interventions.
  • Implementation. Implementation has only recently been identified as an area of research in its own right. The effectiveness of state and community-level implementation processes and approaches is one of the frontiers of future prevention research.
  • Analysis of adaptation. Little research has addressed factors that either facilitate or impede the transfer or adaptation of evidence-based interventions that have been developed for a single setting to a range of other ethnic, linguistic, and cultural groups. Additional research is needed to ensure the availability of interventions that are culturally relevant and that have been informed by the nation’s many ethnic, linguistic, and cultural environments.
  • Linkages with neuroscience. Environment and experience have powerful effects on modifying brain structure and function, including influences on the expression of genes and their protein products that can dictate or alter the course of development. Cross-disciplinary collaborations that formulate and test hypotheses concerning the roles and interactions among multiple genetic and epigenetic influences on brain development may lead to strategies to tailor preventive interventions to specific individuals or groups of individuals at greatest risk.
  • Economic analyses. The challenges of conducting economic analyses and the relative novelty of this type of analysis in the prevention field suggest the need for guidelines for conducting economic analyses (cost-effectiveness and cost-benefit analyses) as well as provision of incentives to encourage their inclusion in study designs. Evidence of the economic benefits of preventive interventions will make them more valuable to communities as they decide about the distribution of limited resources.
  • Competencies. Competencies related to age-appropriate developmental tasks in the family, school, peer group, and community play an important role in mental health. The etiology and development of competencies need to be better understood. Methods to assess the relative value and effects of different types of competencies on development of and protection from disorders require attention.
  • Use of technology. The Internet, mass media, and other current technologies (e.g., CD-ROMs) represent potential mechanisms to reach large segments of the population. Research in this area should be conducted to determine whether such media can be used effectively to promote mental health or to prevent disorders.
  • Other research gaps. Despite dramatic increases in prevention research, significant gaps remain regarding populations and settings to be targeted.

Given the modest effect sizes of some interventions, research funders are encouraged to support research to improve the breadth of the application and effectiveness of current evidence-based interventions and to develop new, more effective interventions. They should also direct researchers to measure outcomes over time, ideally across developmental periods, analyze multiple outcomes (including the effects on multiple disorders), and assess iatrogenic effects. Researchers in turn are encouraged to design interventions and evaluations that respond to these concerns (see Box S-5).

Finally, the gap is substantial between what is known and what is actually being done. The nation is now well positioned to equip young people with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships that strengthen the social fabric. This can be achieved by refining the science and by developing the infrastructure and large-scale collaborative systems that allow the equitable delivery of population-based preventive approaches. We call on the nation to build on the extensive research now available by implementing evidence-based preventive interventions, testing their effectiveness in specific communities, disseminating principles in support of prevention, addressing gaps in the available research, and monitoring progress at the national, state, and local levels.

Footnotes

1

The term “research funders” is used throughout the recommendations to refer to federal agencies and foundations that fund research on mental health promotion or prevention of MEB disorders.

Copyright © 2009, National Academy of Sciences.
Bookshelf ID: NBK32776

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