1
Introduction

Mental, emotional, and behavioral (MEB) disorders—such as depression, conduct disorder, and substance abuse—among children, youth, and young adults create an enormous burden for them, their families, and the nation. They threaten the future health and well-being of young people. Between 14 and 20 percent of young people experience an MEB disorder at a given point in time. A survey of adults reported that half of all lifetime cases of diagnosable mental illness began by age 14 and three-fourths by age 24 (Kessler, Berglund, et al., 2005). A review of three longitudinal studies concluded that close to 40 percent of young people have had at least one psychiatric disorder by the time they are 16 (Jaffee, Harrington, et al., 2005). Furthermore, about one in five (21.3 percent) adolescents ages 12-17 received treatment or counseling for MEB disorders in 2006 (Substance Abuse and Mental Health Services Administration, 2007b). Signs of potential MEB disorders are often apparent at a very young age. Parents often report concerns before age 5, and there are indications that the expulsion rate of children from preschool for behavioral concerns is higher than similar expulsion rates of children from grades K-12 (Gilliam and Sharar, 2006). But mental health costs are often hidden from national accounting methods because a major portion of these costs do not take place in mental health care settings, accruing instead to such systems as education, justice, and physical health care. By the same token, the savings that can accrue from prevention are likely to most benefit these systems.

Early onset of MEB disorders is predictive of lower school achievement, an increased burden on the child welfare system, and greater demands



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1 Introduction M ental, emotional, and behavioral (MEB) disorders—such as depression, conduct disorder, and substance abuse—among chil- dren, youth, and young adults create an enormous burden for them, their families, and the nation. They threaten the future health and well-being of young people. Between 14 and 20 percent of young people experience an MEB disorder at a given point in time. A survey of adults reported that half of all lifetime cases of diagnosable mental illness began by age 14 and three-fourths by age 24 (Kessler, Berglund, et al., 2005). A review of three longitudinal studies concluded that close to 40 percent of young people have had at least one psychiatric disorder by the time they are 16 (Jaffee, Harrington, et al., 2005). Furthermore, about one in five (21.3 percent) adolescents ages 12-17 received treatment or counseling for MEB disorders in 2006 (Substance Abuse and Mental Health Services Administration, 2007b). Signs of potential MEB disorders are often appar- ent at a very young age. Parents often report concerns before age 5, and there are indications that the expulsion rate of children from preschool for behavioral concerns is higher than similar expulsion rates of children from grades K-12 (Gilliam and Sharar, 2006). But mental health costs are often hidden from national accounting methods because a major portion of these costs do not take place in mental health care settings, accruing instead to such systems as education, justice, and physical health care. By the same token, the savings that can accrue from prevention are likely to most benefit these systems. Early onset of MEB disorders is predictive of lower school achievement, an increased burden on the child welfare system, and greater demands 5

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6 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS on the juvenile justice system (Institute of Medicine, 2006b). One study estimated that more than one-quarter of the total costs for mental health treatment services among adolescents were incurred in the education and juvenile justice systems (Costello, Copeland, et al., 2007). One estimate puts the total annual economic costs in 2007 at roughly $247 billion (Eisenberg and Neighbors, 2007). In addition, youth with emotional and behavioral problems are at greatly increased risk of psychiatric and substance abuse problems (Gregory, Caspi, et al., 2007). The earlier young people start drinking, the more likely they are to have serious alcohol dependence as adults (Grant and Dawson, 1997; Gruber, DiClemente, et al., 1996). Early aggressive behavior greatly increases the risk of conduct disorder, drug use, and other externalizing behaviors, while environmental and individual-level protective factors (Kellam, Ling, et al., 1998) and preventive interventions can reduce these risks. The good news, as this report documents, is that research has identified multiple factors that contribute to the development of MEB disorders, and interventions have been developed to successfully intervene with these fac- tors. Through the application of policies, programs, and practices aimed at eliminating risks and increasing strengths, there is great potential to reduce the number of new cases of MEB disorders and significantly improve the lives of young people. A variety of factors—including individual competencies, family resources, school quality, and community-level characteristics—can increase or decrease the risk that a young person will develop an MEB disorder or related problem behaviors, such as early substance use, risky sexual behavior, or violence. These factors tend to have a cumulative effect: A greater number of risk factors (and for some, a longer exposure, such as from parental mental illness) increases the likelihood of negative outcomes, and a greater number of protective factors (e.g., resources within an indi- vidual, family strengths, access to mentors, and good education) decreases the likelihood of negative outcomes. This report makes the case that pre- venting the development of MEB disorders and related problems among young people, reducing risks, and promoting positive mental health should be high priorities for the nation. Families, policy makers, practitioners, and scientists share a concep- tual commitment to the well-being of young people—that is not a new idea. However, a solid body of accumulated research now shows that it is possible to positively impact young people’s lives and prevent many MEB disorders. In addition, a consensus is emerging around the need to promote positive aspects of emotional development. While additional research is needed, the efficacy of a wide range of preventive interventions has been established, particularly ones that reduce risk factors or enhance protective factors. Less research had been conducted to empirically evaluate strate-

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7 INTRODUCTION gies to implement relevant policies on prevention, to widely and effectively adopt preventive interventions, to develop culturally relevant interventions, or to build the infrastructure for prevention, so that effective practices are available to every family and young person who could benefit from them. 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 dis- ease 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 mobi- lize 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 ill- ness 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

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8 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS 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 demon- strated 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 dif- ferent strategies. For example, strategies at multiple levels have led to effec- tive 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 Medi- cine, 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 pre- ventive 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 chil- dren 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.

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 INTRODUCTION 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 pre- ventive 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 pre- vention. 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 predomi- nant 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 interven- ing 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.

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20 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS 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., nega- tive 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 pro- moting 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 dis- orders 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 disor- ders 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 Medi- cine (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

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2 INTRODUCTION 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 coordina- tion among federal agencies. Numerous other reports and activities have emerged since the 1994 IOM report, drawing more attention to the need for research, preven- tion, 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 Work- group 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. 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 requir- ing 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 con- trolled trials (RCTs), an approach generally considered to be the “gold stan- dard” 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

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22 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 1-1 Timeline of Recent Prevention-Related Events 1994 The Institute of Medicine (IOM) published Reducing Risks for Mental Dis- orders: Frontiers for Preventive Intervention Research, which presented 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. 1996 The Center for the Study and Prevention of Violence at the University of Colorado at Boulder, with funding from the U.S. Department of Justice, designed and launched a national violence prevention initiative called Blueprints for Violence Prevention to identify effective violence prevention programs. 1997 As part of a model programs initiative, the Center for Substance Abuse Prevention of the Substance Abuse and Mental Health Services Admin- istration (SAMHSA) created the National Registry of Effective Prevention Programs. The National Institute on Drug Abuse (NIDA) released Preventing Drug Use Among Children and Adolescents: A Research-Based Guide for Parent, Educators, and Community Leaders, which includes examples of research-based drug abuse prevention programs. 1998 The National Research Council (NRC) and IOM held a workshop on adolescent decision making and its implications for prevention programs; the workshop report summarized issues raised related to the design and implementation of prevention programs for youth. The National Advisory Mental Health Council’s Workgroup on Mental Disorder Prevention Research of the National Institute of Mental Health (NIMH) released Priorities for Prevention Research at NIMH. The Promising Practices Network (PPN) was launched by a partner- ship between four state-level intermediary organizations with the goal of encouraging a shift toward results-oriented policy and practice by provid- ing easier access to evidence-based information via the Internet. The site, which is now administered by RAND, provides information about “what works” to improve the lives of children, youth, and families. Programs are reviewed and assigned to one of the evidence level categories (proven, promising, proven/promising, and screened). 1999 Mental Health: A Report of the Surgeon General was issued to address mental health and mental illness across the life span, focusing attention on the role of mental health, including prevention of disorders, in the lives of individuals, communities, and the nation. The Safe and Drug Free Schools Act created a new interagency program (U.S. Department of Education, U.S. Department of Health and Human Services, and Office of Juvenile Justice and Delinquency Prevention) to

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2 INTRODUCTION prevent violence and substance abuse among the nation’s youth, schools, and communities. The act specifies “principles of effectiveness.” The Surgeon General’s Call to Action to Prevent Suicide proposed “a nationwide, collaborative effort to reduce suicidal behaviors, and to prevent premature death due to suicide across the life” by using AIM (awareness, intervention, and methodology) as an approach to address suicide. The American Academy of Pediatrics’ Task Force on Violence published The Role of the Pediatrician in Youth Violence Prevention in Clinical Prac- tice and at the Community Level. 2000 The Society for Prevention Research (SPR) released the first edition of its flagship journal, Prevention Science, as an interdisciplinary forum designed to disseminate new developments in the theory, research, and practice of prevention. (SPR was created in 1991 to advance science- based prevention programs and policies through empirical research.) Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda was released, which introduces a “blueprint for addressing children’s mental health in the United States” based on a conference sponsored by the U.S. Departments of Health and Human Services, Education, and Justice. The World Federation for Mental Health, the Clifford Beers Foundation, and the Carter Center Mental Health Program organized the First World Conference on the Promotion of Mental Health and Prevention of Mental and Behavioral Disorders. 2001 Youth Violence: A Report of the Surgeon General reviewed the factors that protect youth from perpetrating violence and identified effective research- based preventive strategies. The Coalition for Evidence-Based Policy was established to promote govern- ment policy making based on rigorous evidence of program effectiveness. Mental Health: Culture, Race, and Ethnicity (a supplement to Mental Health: A Report of the Surgeon General) was released by the Office of the Surgeon General. The National Advisory Mental Health Council’s Workgroup on Child and Adolescent Mental Health Intervention Development and Deployment released Blueprint for Change: Research on Child and Adolescent Mental Health. The American Psychological Association released a special issue of Pre- vention and Treatment, with 13 commentaries on the 1998 report Priorities for Prevention Research at NIMH. Child Trends published two reports on mental health and emotional well- being, Background for Community-Level Work on Mental Health and Externalizing Disorders in Adolescence: Reviewing the Literature on continued

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24 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 1-1 Continued Contributing Factors and Background for Community-Level Work on Emo- tional Well-Being in Adolescence: Reviewing the Literature on Contributing Factors, as part of its series of “what works” in youth development. 2002 The IOM published Reducing Suicide: A National Imperative, which includes consensus statements on the scientific literature on the causes of and risk factors for suicide and illuminates contentious issues and gaps in the knowledge base that should guide prevention efforts and intervention. The What Works Clearinghouse was established by the U.S. Department of Education’s Institute of Education Sciences to provide educators, policy makers, researchers, and the public with a central and trusted source of scientific evidence for what works in education, including programs aimed at character education. The President’s New Freedom Commission on Mental Health was estab- lished to identify policies that could be implemented by federal, state, and local governments to maximize the utility of existing resources, improve coordination of treatments and services, and promote successful commu- nity integration for adults with a serious mental illness and children with a serious emotional disturbance. 2003 The President’s New Freedom Commission on Mental Health released Achieving the Promise: Transforming Mental Health Care in America, rec- ommending a wholesale transformation of the nation’s mental health care system that involves consumers and providers, policy makers at all levels of government, and the public and private sectors. NIDA released a second edition of Preventing Drug Use Among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders. NIMH released Breaking Ground, Breaking Through: The Strategic Plan for Mood Disorders Research, which included a section titled “Treatment, Prevention, and Services: Improving Outcomes.” The Congressional Mental Health Caucus was established to “discuss awareness and find solutions in a bipartisan manner on improving mental health care and its delivery to every American.” 2004 The NRC and IOM published Reducing Underage Drinking: A Collective Responsibility, which explored the ways in which different individuals and groups contribute to the problem of underage drinking and how they can be enlisted to prevent it. SPR issued Standards of Evidence: Criteria for Efficacy, Effectiveness and Dissemination. The New England Regional Conference on Evidence-Based Programs for the Promotion of Mental Health and Prevention of Mental and Substance

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25 INTRODUCTION Abuse Disorders was sponsored by the New England Coalition for Health Promotion and Disease Prevention (NECON), with funding support from the Center for Mental Health Services (CMHS) in SAMHSA. NIMH and NIDA sponsored a two-day meeting to consider research on the prevention of depression in children and adolescents and to consider new opportunities to develop further the empirical base for additional preven- tive approaches. Following the meeting, some of the participants prepared articles for a special issue of the American Journal of Preventive Medicine (Volume 31, Issue 6, Supplement 1, pp. 99-188, December 2006). The National Council for Suicide Prevention issued the National Strategy for Suicide Prevention to promote broad collaboration in prevention activities. 2006 The World Federation of Mental Health established an Office for the Pro- motion of Mental Health and Prevention of Mental Disorders. 2007 SAMHSA launched a new, expanded website to review mental health and substance abuse programs and practices. The system is renamed the National Registry of Evidence-Based Programs and Practices (NREPP). The surgeon general released The Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking. The American Psychological Association hosted a congressional briefing entitled “Children’s Mental Health: Key Challenges, Strategies, and Effec- tive Solutions,” with a focus on prevention. Psychiatric Annals published a series of articles on prevention in the field of psychiatry. This issue provided a survey of the recent literature on prevention topics for practicing clinical psychiatrists, such as prevention psychiatry, suicide prevention, prodromal states and early intervention in psychosis, alcohol and drug abuse prevention, adverse childhood events as risk factors, becoming a preventionist, and a resident’s perspective on prevention in psychiatry. The Carter Center convened its annual Rosalynn Carter Mental Health Policy Symposium, with a focus on prevention. The National Co-Morbidity Study provided additional data confirming that half of all lifetime diagnosable mental illness begins by age 14. SAMHSA released a report to Congress, Promotion and Prevention in Mental Health: Strengthening Parenting and Enhancing Child Resilience. 2008 Congress included a requirement in the FY 2008 budget of the U.S. Department of Health and Human Services to implement an evidence- based wellness and prevention initiative in the mental health program of regional and national significance and an evidence-based home visitation program within the child abuse and neglect program. Mental Health America launched an Inaugural Promotion and Prevention Summit.

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26 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS 50 45 Randomized Controlled Trials 40 Number of Published 35 30 25 20 15 10 5 0 1980 1983 1986 1989 1992 1995 1998 20 01 20 04 20 07 Year FIGURE 1-1 Growth in randomized controlled trials. Fig1-1.eps 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 out- comes, 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. 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 mecha- nism 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 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. 2The 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.

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27 INTRODUCTION Institute on Drug Abuse, 1997; National Institute on Alcohol Abuse and Alcoholism, 2002; Maryland Governor’s Office of Crime Control and Pre- vention, 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 documenta- tion of efficacious interventions that successfully reduce an array of risk fac- tors or enhance protective factors for MEB disorders and substance abuse. Increasingly, there is evidence that some of these interventions can be effec- tively 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 dis- orders of young people remains a challenge. Prevention science and prac- tice 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

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28 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS 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 psychosocial research as well as the field of prevention science. • Highlight areas of key advances and persistent challenges since the publica- tion of the 1994 IOM report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. • Examine the research base within a developmental framework throughout the life span, with an emphasis on prevention and promotion opportunities that can improve the mental health and behavior of children, youth, and young adults. • Review the current scope of federal efforts in the prevention of mental dis- orders and substance abuse and the promotion of mental health among at-risk populations, including children of parents with substance abuse or mental health disorders, abused and neglected children, children in foster care, children whose parents are absent or incarcerated, and children exposed to violence and other trauma, spanning the continuum from research to policy and services. • Recommend areas of emphasis for future federal policies and programs of research support that would strengthen a developmental approach to a pre- vention research agenda as well as opportunities to foster public- and private- sector collaboration in prevention and promotion efforts for children, youth, and young adults, particularly in educational, child welfare, and primary care settings. • Prepare a final report that will provide a state-of-the-art review of prevention research. 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. Terminology The committee’s charge references “mental disorders, substance abuse, and problem behaviors.” “Mental disorders” are defined by a cluster of symptoms, often including emotional or behavioral symptoms, codified in

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2 INTRODUCTION the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). They include a variety of conditions, such as schizophrenia, depression, conduct disorder, attention deficit hyperactivity disorder, and anxiety disorder. Although the DSM and ICD criteria are widely used for diagnostic purposes, federal agencies have adopted alternative terminology, such as “mental and behavioral disorders,”3 “emotional, behavioral and mental disorders,”4 and “mental, emotional, and behavioral disorders”5 to communicate information about the range of disorders experienced by young people. The National Asso- ciation of School Psychologists has identified children with “emotional and behavioral disorders”6 as needing focused attention in the education system. Similarly, health care professionals are seeing significant numbers of children as a result of parental concerns regarding their behavior. The committee debated the term to use for purposes of this report, weighing the potential implications for the DSM and the ICD, the stigma often associated with the term “mental disorders,” and the perspectives of the multiple audiences at whom the report is aimed—including researchers; service providers in the education, health, and social service systems; and parents themselves. Although “mental disorders” is the accepted term among many in diagnostic roles, less stigmatizing terminology is likely to resonate with others, including parents and school personnel. In the end, the committee decided to use “mental, emotional, and behavioral (MEB) disorders” based on its comprehensiveness, relevance to multiple audiences, and reduced stigma. More specific terminology is used when the discussion refers to a specific disorder. Substance abuse and dependence are mental disorders included in the DSM and diagnosed when symptoms and impairment reach a high level. However, substance use, including underage drinking, is a problem behav- ior of significant public health concern even when the symptoms are not severe enough to be considered a substance use disorder. Such problem behaviors as early substance use, violence, and aggression are often signs or symptoms of mental disorders, although they may not be frequent or severe enough to meet diagnostic criteria. Nonetheless, intervention when these signs or symptoms are apparent, or actions to prevent them from occurring in the first place, can alter the course toward disorder and, as this report outlines, are an important component of prevention in this area. The committee could not thoroughly consider the complete range of behaviors (e.g., truancy, unprotected sex, reckless driving) that might be considered 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.

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0 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS problem behaviors among young people. Prevention of substance use is included in the report given the inclusion of substance abuse in our charge; discussion of other problem behaviors is intended to illustrate the synergy in risk factors and approaches to prevention. Similarly, for ease of reading, the committee has adopted the term “young people” throughout the report when referring to “children, youth, and young adults” as a group. When the discussion of a particular topic or preventive approach applies to a specific developmental phase (e.g., child- hood, adolescence), the relevant descriptor (e.g., children) is used instead. Scope of the Study In general, prevention research is focused on the factors empirically demonstrated to be associated with MEB disorders, either as risk factors, protective factors, or constructive interventions to reduce them; risk fac- tors often represent risks for multiple disorders or problem behaviors. In addition, relatively few studies to date measure the incidence of actual MEB disorders as an outcome. The committee’s review focuses on the developmental processes and factors that modify mental, emotional, and behavioral outcomes, rather than on individual disorders. When evidence is available related to the prevention of specific disorders (e.g., depression, schizophrenia, substance abuse), as opposed to risks for disorders, we have presented it as well. Over the long term, studies to address risk factors and improve the lives of children as well as studies to demonstrate the effects of interventions on the actual incidence of disorders are needed. Given the extensive work already done by the IOM and others on smoking prevention, substance abuse was interpreted to mean primarily prevention of alcohol and drug use, with a focus on the trajectories and mechanisms they share with other mental, emotional, or behavioral prob- lems. We do not provide a comprehensive epidemiological review of use of various substances by this population. Lessons from smoking are drawn on when appropriate. The committee considers problem behaviors, such as risky sexual behavior and violence, to be integrally related to future mental, emotional, and behavioral problems among young people, with common trajectories and risk factors associated with both. HIV preventive interventions aimed at reducing risky sexual behavior as well as interventions designed to pre- vent violence are included in our review. The committee was not asked to consider the status of treatment. Although we recognize that there are significant issues related to the quality and accessibility of treatment for young people (Burns, Costello, et al., 1995; Masi and Cooper, 2006), this was outside our charge. Still, given our charge to focus on promotion and prevention, we have articulated

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 INTRODUCTION distinctions among what is considered promotion, prevention, and treat- ment. However, as discussed in more detail later in the report, there is no bright line separating promotion from prevention or prevention from treatment. We hope that readers of the report will appreciate that mental health promotion, prevention of mental health disorders, and treatment lie on a continuum, with each aspect of the continuum warranting attention. We also hope that the distinctions we draw among them will help guide policy, research, and funding decisions to ensure that progress in the areas of mental health promotion and prevention can accelerate. Unlike the 1994 IOM report, the committee has embraced mental health promotion as an integral component of the continuum that warrants attention. The committee also recognizes that the term “prevention” applies to multiple fields of health. However, for simplicity, as used in this report, the term refers to prevention of mental, emotional, and behavioral problems rather than prevention of other sources of illness and disability. The committee met five times during the course of the study and com- missioned a series of papers on evidence related to early childhood, school- based, family-based, community-based, and culturally specific interventions, intervention cost-effectiveness, and aspects of screening and assessment. At the beginning of our deliberations, the committee heard from a variety of professional and other organizations actively involved in children’s mental health issues. We convened a full-day workshop to hear from experts rep- resenting a variety of methodological issues, prevention approaches, and policy considerations. The workshop also included a panel to discuss recent developments in epigenetics and developmental neuroscience and a series of presentations on issues specific to youthful alcohol use (see Appendix B for a list of public meetings and presenters7). In addition to an assessment of the evidence by leading experts at the workshop, the committee reviewed available meta-analyses and systematic reviews regarding prevention and promotion and key literature since 1994 related to our charge. 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 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.

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2 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS developmental pathways that may lead to disorder and provide an empiri- cal 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 epi- genetics and gene–environment interactions that present potential interven- tion opportunities (Chapter 5). Part II includes two chapters that present the evidence related to inter- ventions 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 ben- efits 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 sci- ence. 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 repre- sents 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 chap- ter that provides summative observations about the future of prevention (Chapter 13).