CORE CONCEPTS

Several core concepts underlie the ability to adopt prevention and promotion as national priorities. The committee views these concepts as essential elements that must be embraced by families, policy makers, service systems, and scientists in order to continue to make progress in this area. They also shed light on why not enough attention has been directed to prevention or promotion to date.

Prevention requires a paradigm shift. Prevention of MEB disorders inherently involves a way of thinking that goes beyond the traditional disease model, in which one waits for an illness to occur and then provides evidence-based treatment. Prevention focuses on the question, “What will be good for the child 5, 10, or more years from now?” and tries to mobilize resources to put these things in place. A growing body of prevention research points to the need for the national dialogue on mental health and substance abuse issues to embrace the healthy development of young people and at the same time to respond early and effectively to the needs of those with MEB disorders.

Mental health and physical health are inseparable. The prevention of MEB disorders and physical disorders and the promotion of mental health and physical health are inseparable. Young people who grow up in good physical health are more likely to also have good mental health. Similarly, good mental health often contributes to maintenance of good physical health. In their calculations of the burden of disease and injury in the United States in 1996 (the latest data available), Michaud, McKenna, and colleagues (2006) show that in children ages 5–14, 15 percent of disability-adjusted life years (DALYs) lost to illness are caused by mental illness. In youth ages 15–24, almost two-thirds of DALYs lost are due to mental illness, to substance abuse, or to homicide, suicide, or motor vehicle accidents, all of which have a strong association with mental illness and substance abuse. Furthermore, MEB disorders increase the risk for communicable and noncommunicable diseases and contribute to both intentional and unintentional injuries, so the percentage may be even higher (Prince, Patel, et al., 2007). Almost one-quarter (24 percent) of pediatric primary care office visits involve behavioral and mental health problems (Cooper, Valleley, et al., 2006).

Conversely, young people with special health care needs or chronic physical health problems are at greater risk for MEB disorders (Kuehn, 2008; Wolraich, Drotar, et al., 2008). Associations have been demonstrated between MEB disorders and a number of chronic diseases. For example, one study showed that 16 percent of asthmatic youth ages 11–17 demonstrated criteria for anxiety and depressive disorders (McCauly, Katon, et al., 2007). Health professionals in both sectors contribute to the maintenance of good physical and good mental health.

Successful prevention is inherently interdisciplinary. The prevention of MEB disorders is inherently interdisciplinary and draws on a variety of different strategies. For example, strategies at multiple levels have led to effective tobacco control and reductions in underage drinking. These include broad interventions that address policy or regulation (product taxation, purchase and use age minimums, advertising restrictions), interventions that address community behaviors (blue laws, smoke-free workplaces), interventions within the legal system (fines for underage sales, lawsuits against manufacturers), and individually focused interventions both within and independent of the health care system (parents educating their children about smoking and drinking).

Mental, emotional, and behavioral disorders are developmental. The health status of young people has a significant influence on the trajectory of health into adulthood (National Research Council and Institute of Medicine, 2004a). While research suggests that the earliest years of life are one of the most opportune times to affect change (National Research Council and Institute of Medicine, 2000), other developmental periods (e.g., early adolescence) or settings (e.g., schools) in young people’s lives also provide opportunities for intervention (National Research Council and Institute of Medicine, 2001, 2002). Children develop in the context of their families (or, for some, the institutions that replace their families), their schools, and their communities.

Coordinated community-level systems are needed to support young people. Supporting the development of children requires that infrastructure be in place in one or more systems—public health, health care, education, community agencies—to support and finance culturally appropriate preventive interventions at multiple levels. Similarly, the benefits or savings of prevention may occur in a system (e.g., education, justice) other than the one that paid for the prevention activity (e.g., health), requiring a broad, community-wide perspective. For example, an outcome of a family-based preventive intervention delivered by the health care system may be children who are more successful academically or have fewer legal difficulties. Sharing costs and benefits of interventions across agencies and programs would likely create new opportunities for broad advances.

INTERVENTION RATIONALE

The past decade and a half has witnessed an explosion in knowledge regarding how to help young people experience healthy development. The evidence that these efforts can have a positive impact on the trajectory of their lives makes a compelling case for them. However, there have been strong pressures by some public interest groups against many types of preventive interventions. Objections have been particularly strong related to mandatory screening of children to identify those at high risk and therefore presumably in need of prevention or treatment, as well as to screening done with passive consent. Concerns have also been raised about the reliability of screenings conducted to identify suicide risk, as well as the effectiveness of preventive interventions designed to reduce suicide (Institute of Medicine, 2002).

Public views about mental health treatment and prevention often differ; this is certainly true in the United States. Insurance and government-funded programs typically support treatment but do so less for many kinds of prevention. A fundamental difference between some forms of prevention and treatment is that treatment is typically based on a one-on-one relationship between a person seeking care and a provider of care, whereas prevention can be on an individual (e.g., early child health screenings), group (e.g., a classroom behavior management program), or population (e.g., antidrug advertising campaigns or citywide antibullying programs) basis. In the case of prevention, the public sector, in the shape of a legislative body or a school system, sometimes takes it on itself to intervene in the lives of individuals in the interest of the common good. Public resistance may result when this public intervention infringes on individual rights. For example, the predominant view in the United States is that parenting—unless it results in abuse or neglect—is a private matter not subject to government intervention.

Both the practical public health context and various philosophical contexts provide strong justification for taking a preventive approach to the emotional and behavioral problems of youth. First, public health’s core focus is preventing rather than treating disease. The primary concern is the health of the population, rather than the treatment of individual diseases. Public health recognizes the importance of identifying and then intervening with known risk factors. In a public health context, population health is understood to result from the interaction of a range of factors beyond the individual. In the case of children, youth, and young adults, a public health model would call for the involvement of families, schools, health and other child service systems, neighborhoods, and communities to address the interwoven factors that affect mental health. Behavioral health could learn from public health in endorsing a population health perspective.

From a philosophical perspective, promoting the general welfare and protecting society’s most vulnerable individuals are part of the nation’s foundation, codified in the founding documents of the nation. Government has an obligation to ensure the health, safety, and welfare of its citizens. Thus, government has a responsibility to address unmet mental health needs, particularly for children.

Second, economics suggests that the public sector should intervene when one person’s action or behavior adversely impacts others (i.e., negative externalities). Young people who suffer from MEB disorders impose costs on society beyond those that they suffer themselves: the costs of health and other care; disruptions of work, school, or family; the costs to the criminal justice system and other service systems for actions resulting from MEB disorders; and, in the case of young people, the costs of special education or other remedial services. Preventing MEB disorders and promoting mental health thus benefits not only the individuals who would have directly experienced these problems and their families, but also society as a whole. Similarly, the basic human suffering that individuals with MEB disorders and their families experience calls for public preventive intervention, as there are strategies available that can avoid some of that suffering.

Third, a political science perspective calls on government to intervene in areas in which shared interests require shared solutions—such issues as public education, global warming, national defense, and others for which wider societal action is needed. Political science considers inequities when considering how and when society should be involved in the affairs of its citizens. The distribution of the burden imposed by preventable MEB disorders is one such inequity warranting collective decision making to include population-level issues that affect communities as a whole. Finally, the basic ethical principles of justice, beneficence, and fidelity call for reasonable actions to protect the nation’s young people and promote their well-being.

Collectively, these different perspectives provide a strong rationale for government to employ its resources to prevent a large future burden of MEB disorders that, directly or indirectly, affects all of society. The case is particularly compelling in the instance of preventable disorders among young people. Government, communities, and families should be called on to make changes with documented benefit in their lives.

STUDY BACKGROUND

In 1994, in response to a congressional request, the Institute of Medicine (IOM) published Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, a landmark assessment of research related to prevention of mental disorders (referred to throughout as the 1994 IOM report). The report acknowledged incremental progress since the nation was first called to pay attention to mental illness and its prevention by President John F. Kennedy in the early 1960s. The report provided a new definition of mental illness prevention and a conceptual framework that emphasized the reduction of risks for mental disorders. And it proposed a focused research agenda, with recommendations on how to develop effective intervention programs, create a cadre of prevention researchers, and improve coordination among federal agencies.

Numerous other reports and activities have emerged since the 1994 IOM report, drawing more attention to the need for research, prevention, and treatment of mental disorders (see Box 1-1 for a timeline of key events), including the New Freedom Commission on Mental Health report (2003), reports of the National Advisory Mental Health Council’s Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment (2001) of the National Institute of Mental Health, and reports from the surgeon general on children’s mental health (U.S. Public Health Service, 2000), violence (U.S. Public Health Service, 2001c), and suicide prevention (U.S. Public Health Service, 1999b, 2001b). The Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking (U.S. Public Health Service, 2007) similarly called for concerted national action to address this significant concern affecting young people. Mental health and substance abuse professional and consumer organizations have taken steps to embrace prevention without abandoning the need for treatment.

BOX 1-1

Timeline of Recent Prevention-Related Events.

At the same time, the growth in research-based evidence and new government mandates related to program accountability have prompted focused attention on specific preventive interventions. The Government Performance and Results Act of 1993 launched a trend toward requiring federal programs to provide evidence of effectiveness (U.S. Office of Management and Budget, 2003). The Safe and Drug Free Schools Act of 1990 specified “principles of effectiveness,” and the No Child Left Behind Act of 2001 called for school districts to implement evidence-based programming (Hallfors and Godette, 2002). More recently, the Consolidated Appropriations Act of 2008 created a new grant program to support “evidence based home visitation programs” that meet “high evidentiary standards” as well as a new wellness program in the mental health programs of regional and national significance that would require grantees to “evaluate the success of the program based on their ability to provide evidence-based services.”

The number of preventive interventions tested using randomized controlled trials (RCTs), an approach generally considered to be the “gold standard” and strongly recommended by the 1994 IOM report, has increased substantially since that time. Figure 1-1 illustrates the number of published RCTs (between 1980 and 2007) based on a search of articles related to preventive interventions for MEB disorders with young people included in Medline and Psychinfo.¹ Although there may be some published (and clearly unpublished) RCTs that were not identified by this search, the overall trend is unlikely to be affected. While not all of the articles report successful interventions or interventions that have a major impact on outcomes, the evidence base available now is significantly advanced beyond what was available at the time of the 1994 IOM report.² Similarly, other types of evaluations that provide meaningful insights into mental health promotion and the prevention of MEB disorders have also been conducted. Although RCTs remain the gold standard, they are not always feasible, and other designs can make important contributions.

FIGURE 1-1

Growth in randomized controlled trials.

Some federal programs have directed that resources be used only for programs with evidence of effectiveness, and numerous efforts have emerged to identify and share model programs or best practices. The Substance Abuse and Mental Health Services Administration, the U.S. Department of Justice, and the U.S. Department of Education have each launched a mechanism to identify and disseminate information about interventions, including many preventive interventions. Numerous federal and state organizations have published guides or lists of “model” or “effective” programs (National Institute on Drug Abuse, 1997; National Institute on Alcohol Abuse and Alcoholism, 2002; Maryland Governor’s Office of Crime Control and Prevention, 2003). However, there is wide variation in the evidence criteria used to identify and classify programs as well as the terminology used to describe them (research-based, evidence-based, model, promising, etc.). Impressive advances have been made in the development and documentation of efficacious interventions that successfully reduce an array of risk factors or enhance protective factors for MEB disorders and substance abuse. Increasingly, there is evidence that some of these interventions can be effectively implemented in community settings. And there is a relatively young but growing body of evidence that some interventions are cost-effective.

Despite these substantial developments, translating existing knowledge into widespread reductions in the incidence and prevalence of MEB disorders of young people remains a challenge. Prevention science and practice still lack empirically tested strategies for widespread dissemination of evidence-based interventions and an infrastructure of schools, family service organizations, or health care providers to reliably deliver evidence-based interventions.

The astonishing number of young people with MEB disorders has placed extraordinary demands on the education, child welfare, and justice systems as children and youth with unmet needs enter those systems. As well, it has sparked interest in preventive approaches that may help stem the tide. Many interventions have been demonstrated to be efficacious (i.e., tested in a research environment), and several have been demonstrated to be effective (i.e., tested in the real world). However, implementation of any intervention on a large scale and demonstration that it reliably improves mental health outcomes remain a daunting challenge. Similarly, a shared public vision about prevention of MEB disorders or promotion of mental health, which prioritizes the healthy development of young people and places prevention of MEB disorders on equal footing with physical health disorders, is seriously lacking. Collective attention to the fact that the vast majority of MEB disorders begins in youth will require transformation in multiple systems that work with young people.

THE COMMITTEE’S CHARGE

Recognizing significant changes in the policy and research contexts and substantial increases in the availability of prevention research, 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 that the Board on Children, Youth, and Families of the National Research Council and Institute of Medicine provide an update on progress since release of the 1994 IOM report, Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, with special attention to the research base and program experience with younger populations since that time (see Box 1-2 for the complete charge). The committee was asked to focus on populations through age 25. As mentioned above, most MEB disorders have their origins before this age, and most individuals have adopted adult roles by age 25 (Furstenberg, Kennedy, et al., 2003). In this way, this report differs from the 1994 IOM report, which included the entire life span.

BOX 1-2

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...)

ORGANIZATION OF THE REPORT

The remainder of this report is organized in three parts. Part I provides contextual and background information, beginning with a description of the available epidemiological literature on the prevalence and incidence of MEB disorders (Chapter 2). It then moves to a discussion of the scope of prevention, including the definitions of the various types of prevention and discussion of recent developments and definitions of mental health promotion (Chapter 3). The next two chapters outline perspectives on the developmental pathways that may lead to disorder and provide an empirical and theoretical basis for preventive interventions. The first presents available research on risk and protective factors related to prevention and promotion in a developmental context (Chapter 4). The second focuses on research related to genetics and developmental neuroscience, highlighting developmental plasticity and the important findings from research on epigenetics and gene–environment interactions that present potential intervention opportunities (Chapter 5).

Part II includes two chapters that present the evidence related to interventions aimed at individual, family, and community-level factors associated with mental, emotional, and behavioral outcomes (Chapter 6) and those that either target a specific disorder or are directed at overall promotion of health (Chapter 7). Given the potential relevance of population, group, and individual screening for the targeting of interventions, the next chapter discusses issues and opportunities related to screening (Chapter 8). The costs associated with MEB disorders and the available evidence on the benefits and costs of interventions discussed in Chapters 6 and 7 are discussed in the next chapter (Chapter 9). The last chapter in Part II outlines how methodologies have improved since the 1994 IOM report, methodological and statistical approaches to strengthen inferences, and the advantages of randomized and other designs. It also introduces methodological challenges for the next decade (Chapter 10).

Part III includes chapters that outline the frontiers for prevention science. It begins with a discussion of implementation; although there is an emerging implementation science, neither research nor practice related to implementation has kept pace with the available evidence, and this represents an important area of needed focus for prevention science (Chapter 11). Infrastructure issues, particularly systems concerns, and lack of funding and training are discussed next (Chapter 12). This part closes with a chapter that provides summative observations about the future of prevention (Chapter 13).

Footnotes

1

The search, modeled on the approach used by the Cochrane Collaboration, identified articles that self-identified as an RCT or included such terms as “random,” “control,” and “double” or “single blind” to describe their design. The abstracts of articles identified by the database search were then reviewed to eliminate those that were not an RCT, did not address the prevention of emotional and behavioral disorders, or were not targeted at young people.

2

The committee notes that it typically takes years for the results of an RCT to appear in a journal. As a result, the year of publication may not correspond to the year in which the RCT took place.

3

See http://mentalhealth​.samhsa​.gov/publications​/allpubs/svp05-0151/.

4

See http://www​.mchlibrary​.info/knowledgepaths​/kp_mental_conditions.html.

5

See http://mentalhealth​.samhsa​.gov/publications​/allpubs/CA-0006/default.asp.

6

See http://www​.nasponline​.org/about_nasp/pospaper_sebd.aspx.

7

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