7
Prevention of Specific Disorders and Promotion of Mental Health

The preceding chapter focused on preventive interventions that target change in the systems that most influence the cognitive, emotional, and behavioral development of young people: the family, schools, and the community. This chapter explores available preventive interventions that are targeted at specific mental, emotional, and behavioral (MEB) disorders. Many of these are designed to address the specific risk and protective factors associated with those disorders, although some also target risk factors that are common to multiple disorders.

The disorders targeted by preventive interventions tend to emerge at different development stages; for example, anxiety begins to emerge at a relatively young age, whereas schizophrenia tends to emerge closer to adolescence and young adulthood. Depression, eating disorders, and substance use and abuse tend to become a significant problem in the middle and high school years. The chapter organizes discussion of disorder-specific interventions in terms of the order in which they tend to appear in the developmental course of young people’s lives. Many of the interventions discussed in the previous chapter include among their outcomes improvements in one or more disorders, particularly externalizing disorders (e.g., substance abuse, conduct disorder, attention deficit hyperactivity disorder [ADHD]) (see Box II-1). Those results are not repeated here. Similarly, other low-frequency disorders for which little preventive literature is available, such as bipolar disorder, autism spectrum disorder, and pervasive developmental disorders, are not discussed.

The chapter also includes interventions targeted at mental health promotion, including strategies related to fostering positive development among



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7 Prevention of Specific Disorders and Promotion of Mental Health T he preceding chapter focused on preventive interventions that target change in the systems that most influence the cognitive, emotional, and behavioral development of young people: the family, schools, and the community. This chapter explores available preventive interven- tions that are targeted at specific mental, emotional, and behavioral (MEB) disorders. Many of these are designed to address the specific risk and pro- tective factors associated with those disorders, although some also target risk factors that are common to multiple disorders. The disorders targeted by preventive interventions tend to emerge at different development stages; for example, anxiety begins to emerge at a relatively young age, whereas schizophrenia tends to emerge closer to ado- lescence and young adulthood. Depression, eating disorders, and substance use and abuse tend to become a significant problem in the middle and high school years. The chapter organizes discussion of disorder-specific interven- tions in terms of the order in which they tend to appear in the develop- mental course of young people’s lives. Many of the interventions discussed in the previous chapter include among their outcomes improvements in one or more disorders, particularly externalizing disorders (e.g., substance abuse, conduct disorder, attention deficit hyperactivity disorder [ADHD]) (see Box II-1). Those results are not repeated here. Similarly, other low- frequency disorders for which little preventive literature is available, such as bipolar disorder, autism spectrum disorder, and pervasive developmental disorders, are not discussed. The chapter also includes interventions targeted at mental health pro- motion, including strategies related to fostering positive development among 

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2 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS children and adolescents and to modifying lifestyle factors that have been associated with a range of MEB disorders. The programs described here are delivered across mental health, physical health, and school settings and have involved intervention directly with children, with parents, and with the whole family. The chapter closes with conclusions and recommenda- tions based on the evidence presented in both Chapter 6 and Chapter 7. PREVENTION OF SPECIFIC DISORDERS Prevention of Anxiety Anxiety symptoms and disorders typically emerge in childhood (see Chapter 2); lifetime rates of anxiety disorders by adolescence may be as high as 27 percent (Costello, Egger, and Angold, 2005). Anxiety disorders typi- cally precede depression and may contribute to its development (Wittchen, Beesdo, et al., 2004). Although a number of studies have shown the effec- tiveness of cognitive-behavioral therapy (CBT) in treating anxiety disorders in children and adolescents (Barrett, 1998; Kendall, 1994; Kendall, Safford, et al., 2004; Manassis, Mendlowitz, et al., 2002; Mendlowitz, Manassis, et al., 1999), and there is some evidence of the benefits of anxiety prevention for college-age individuals with anxiety symptoms (Schmidt, Eggleston, et al., 2007; Seligman, Schulman, et al., 1999), relatively little research has been done on the prevention of these disorders. However, Bienvenu and Ginsburg (2007) recently reviewed evaluations of anxiety preventive inter- ventions, most of which were conducted in Australia. All of the interven- tions are variants of CBT applied to prevention, and most involve parents in some way. Rapee (2002) and Rapee, Kennedy, et al. (2005) report a selective intervention for 3- to 5-year-olds whose behavior was inhibited according to parent and child reports and a behavioral assessment. Parents were ran- domly assigned to a no-intervention control condition or to an intervention involving six 9-minute group sessions that taught them how to practice gradual exposure and techniques for dealing with different situations, such as entering school. At 12-month follow-up, the intervention group children had a significantly lower prevalence of anxiety disorders, although there was no effect on parental or maternal ratings of inhibition or inhibition as assessed through behavioral testing. Barrett and colleagues conducted several studies of universal interven- tions to prevent anxiety problems among children and adolescents (Barrett, Lock, and Farrell, 2005; Barrett and Turner, 2001). The interventions con- sist of 10-12 classroom sessions and 4 parent sessions guided by a frame- work called FRIENDS: Feeling worried; Relax and feel good; Inner helpful thoughts; Explore plans; Nice work, reward yourself; Don’t forget to prac-

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 PREVENTION OF SPECIFIC DISORDERS tice; and Stay calm for life (Barrett, Lowry-Webster, and Turner, 2000). Barrett and Turner (2001) randomized 489 children ages 10-12 to one of three conditions: (1) usual care, (2) the program led by a teacher, or (3) the program led by a psychologist. Those assigned to the active interventions had significantly fewer anxiety symptoms at the end of the intervention. In other studies, the program reduced the proportion of 10- to 13-year-olds who were at risk for anxiety problems (Lowry-Webster, Barrett, and Dadds, 2001) and at 12-month follow-up had significantly lowered anxiety among sixth and ninth grade students (Barrett, Lock, and Farrell, 2005). There was some evidence that the intervention produced greater reductions than the control condition for the high- and moderate-risk groups (Barrett, Lock, and Farrell, 2005). Dadds, Spence, and colleagues (1997) evaluated an indicated interven- tion for 7- to 14-year-olds who had anxiety symptoms or who met criteria for an anxiety disorder but did not have severe problems. The interven- tion followed Kendall’s FEAR strategy: Feeling good by learning to relax, Expecting good things to happen, Actions to take in facing up to fear stim- uli, and Rewarding oneself for efforts to overcome fear or worry (Kendall, 1994; Bienvenu and Ginsburg, 2007). The intervention was provided to young people in 10 weekly group sessions; three sessions were provided to help parents learn to manage their own anxiety and to model and encour- age their children’s use of the strategies. Six months after the intervention, young people in the intervention group had significantly fewer anxiety disorders than controls (16 compared with 54 percent). The difference was not significant at one-year follow-up, but it was at two-year follow-up (20 compared with 39 percent). Schmidt, Eggleston, and colleagues (2007) report on a randomized trial of a selective intervention predicated on evidence that sensitivity to anxiety—the fear people have of having anxiety symptoms—is a predictor of the development of anxiety problems. Participants who were high in anxiety sensitivity were randomized to a brief intervention that taught about the symptoms of anxiety and the fact that they are not harmful. Participants were recruited from a university, the community, and local schools, with an average age of 19.3 years. Compared with the no-intervention group, par- ticipants had reduced concerns about the physical and social consequences of anxiety by the end of the program, although the effect was not main- tained at follow-up. Intervention participants were also significantly more comfortable than control participants when exposed to a CO2 challenge that elicits anxiety, and significantly fewer had developed anxiety disorders one to two years after the intervention. Seligman, Schulman, and colleagues (1999) used a randomized design to test an intervention consisting of 10 two-hour group sessions with 231 university students selected on the basis of their pessimistic views compared

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4 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS with controls. The sessions focused on changing cognitions, for example, replacing automatic negative thoughts with more constructive ones. At three-year follow-up, participants had experienced significantly fewer epi- sodes of generalized anxiety disorder and fewer moderate (but not severe) depressive episodes than controls. Although the preventive interventions for anxiety disorders evaluated to date are all based on CBT approaches, recent research suggests that these approaches may not be optimal (Biglan, Hayes, and Pistorello, 2008). Growing evidence suggests greater effectiveness for acceptance-based inter- ventions (Hayes, 2004; Hayes, Luoma, et al., 2006), which teach people to accept anxiety as a normal part of living a value-focused life. Support for this approach also comes from evidence that efforts to control unwanted thoughts and feelings may exacerbate them (e.g., Wegner, 1992, 1994). Additional research is needed to develop and evaluate preventive interven- tions based on acceptance-based approaches and to determine the effective- ness of these approaches relative to traditional CBT. Prevention of Posttraumatic Stress Disorder (PTSD) Although it appears plausible that providing some sort of counseling to all trauma victims could prevent PTSD, empirical research has not shown this to be the case. Critical incident stress debriefing (CISD) is a technique widely used to prevent adverse reactions to trauma. As soon as possible after the traumatic event, victims are encouraged to discuss the details of their experience, their emotional reactions, any actions they have taken, and any symptoms they have experienced. They are reassured that their reac- tions are normal, told of adverse reactions that are typical, and encouraged to resume usual activities. The intervener tries to assess whether any adverse reactions have occurred and, if so, refers the person for further assistance. Typically there is a follow-up contact with the victim. Recent research found that CISD is ineffective and possibly harmful (American Psychiatric Association, 2004). A meta-analysis found no benefit from its use and sug- gested a detrimental effect compared with no intervention or minimal help (van Emmerik, Kamphuis, et al., 2002). In contrast, randomized controlled trials of CBT for individuals who are symptomatic in the weeks after a trauma reveal significant efficacy (Boris, Ou, and Singh, 2005). Some evidence suggests that this includes children (Chemtob, Nakashima, and Hamada, 2002). In a quasi-randomized controlled trial, Berger, Pat-Horenczyk, and Gelkopf (2007) evaluated a school-based intervention consisting of an eight-session structured program designed to prevent and reduce children’s stress-related symptoms, including PTSD. Compared with the wait-list controls, the study group reported significant improvement on all measures.

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5 PREVENTION OF SPECIFIC DISORDERS Finally, there is some evidence that adolescents who maintain their routines have less posttraumatic stress (Pat-Horenczyk, Schiff, and Doppelt, 2006), a finding consistent with other findings that catastrophizing puts individuals at risk for developing PTSD (Bryant and Guthrie, 2005). Prevention of Depression In 1994, when the Institute of Medicine (IOM) report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research was released, available trials of interventions targeting depression were able to demonstrate only a reduction in symptoms (Muñoz and Ying, 1993). Since that time, methods have been developed for consistently identifying individuals at significant risk of experiencing depression within the next year, and some trials have demonstrated a reduction in the incidence of major depressive episodes, particularly among those at high risk (Muñoz, Le, et al., 2008). Of the trials that have shown a significant reduction in new episodes, all have focused either on high-risk adolescents (Clarke, Hawkins, et al., 1995; Clarke, Hornbrook, et al., 2001; Young, Mufson, and Davies, 2006) or pregnant women (Elliott, Leverton, et al., 2000; Zlotnick, Johnson, et al., 2001; Zlotnick, Miller, et al., 2006), and at least one intervention prevented episodes among those who had prior episodes (Clarke, Hornbrook, et al., 2001). On the basis of these advances, Barrera, Torres, and Muñoz (2007) assert that prevention of depression is a fea- sible goal for the 21st century, with the promise of being able to reduce incidence by as much as half. Preventive Interventions for Children and Adolescents Recent meta-analyses have concluded that interventions to prevent depression can reduce both the number of new cases in adolescents (Cuijpers, van Straten, et al., 2008) and depressive symptomatology among children and youth (Horowitz and Garber, 2006). In a review that included seven trials targeting adolescents, Cuijpers and colleagues (2008) report that pre- ventive interventions for adolescents can reduce the incidence of depressive disorders by 23 percent. They caution, however, that since the follow-up period in most studies did not exceed two years, the projects may have delayed onset rather than incidence. Both meta-analyses showed slightly higher effect sizes for selective and indicated interventions, although the number of universal interventions was very small. Significant benefit has been reported for preventive interventions for reducing depressive symptoms in children and adolescents, with small to modest effect sizes (Horowitz and Garber, 2006; Jané-Llopis, Hosman, et al., 2003). In a systematic review of preventive interventions with children

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6 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS and adolescents, Merry and Spence (2007) highlight several promising approaches. However, they also describe failed attempts to repeat results in real-world school and primary care settings, limited follow-up periods, and methodological flaws, and they conclude that there is not yet sufficient evidence of effectiveness for preventive interventions for depression. In an analysis of the high-quality studies reviewed by Horowitz and Garber (2006), Gladstone and Beardslee (in press) demonstrate that although symptom reduction, a powerful goal in itself, is possible, very few studies of adolescents have examined actual reduction in new episodes of major depression, the work of Clarke and colleagues cited above being the notable exception. They emphasize that future studies should examine prevention of episodes as well as reductions in symptomatology. In the committee’s judgment, the balance of evidence suggests that some interventions can significantly reduce the symptomatology and inci- dence of depression. The potential to increase the sample sizes and reach of interventions has been highlighted by work done to adapt behavioral inter- ventions to a range of settings and cultural groups, including conducting worldwide randomized controlled trials via the Internet (Muñoz, Lenart, et al., 2006). The Clarke Cognitive-Behavioral Prevention Intervention (see Box 7-1), an indicated program targeting adolescents at risk for future depression, has successfully prevented episodes of major depression in several randomized trials. A recent replication indicated that it is not as effective for adolescents with a depressed parent (Garber, Clarke, et al., 2007). The Penn Resil- iency Program (PRP) (see Box 7-2), a school-based group intervention that teaches cognitive-behavioral and social problem-solving skills to prevent the onset of clinical depression, has also had promising results. Preventive Interventions for Families with Depressed Parents Children of parents with depression and related difficulties have a sub- stantially higher rate of depression than their counterparts in homes with no mental illness (Beardslee and Podorefsky, 1988; Hammen and Brennan, 2003; Lewinsohn and Esau, 2002; Beardslee, Versage, and Gladstone, 1998; Weissman, Wickramaratne, et al., 2006). They are also at risk for a variety of other difficulties in such areas as school performance and inter- personal relationships (Goodman and Gotlib, 1999). Beardslee and col- leagues developed two public health preventive interventions (see Box 7-3) specifically aimed at providing information and assistance in parenting to children of depressed parents, both of which have shown positive results in multiple randomized trials.

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7 PREVENTION OF SPECIFIC DISORDERS BOX 7-1 Clarke Cognitive-Behavioral Prevention Intervention Program: A Promising Indicated Intervention to Prevent Depression The Clarke Cognitive-Behavioral Prevention Intervention, a 15-session group cognitive-behavioral intervention focused on coping with stress, is modeled after an effective cognitive-behavioral treatment for depression. The first randomized trial targeted adolescents with elevated depressive symptoms and was delivered in schools. At one-year follow-up, intervention participants had a much lower inci- dence of major depressive disorder or dysthymia (14.5 percent) than participants in the usual care control group (25.7 percent) (Clarke, Hawkins, et al., 1995). A second trial broadened the definition of high-risk adolescents to include parental depression and subsyndromal symptoms and recruited 95 adolescents from a health maintenance organization rather than from classrooms (Clarke, Hornbrook, et al., 2001). At 15-month follow-up, participants in the experimental condition showed a much lower rate of major depressive episodes (9.3 percent) than those in the usual care condition (28.8 percent) (p = .003). These results were recently replicated in a four-site randomized trial involving 316 at-risk youths (Garber, Clarke, et al., 2007, in press). Parental depression at the beginning of the inter- vention significantly moderated the effect, however; thus adolescents who had a parent with current depression did not experience a significant reduction in rates of incident depression versus those receiving usual care. Further follow-up of this sample is under way. PREVENTION OF SUBSTANCE USE AND ABUSE School-Based Approaches Many of the interventions discussed in Chapter 6 have had effects on outcomes related to substance abuse. Additional intervention strategies spe- cifically targeting prevention of substance abuse are discussed here. School- based programs with this focus emerge primarily in the middle school years, when initial risk for use is greatest. Cuijpers (2002) reviewed three meta-analyses of classroom-based sub- stance abuse prevention programs (Rooney and Murray, 1996; Tobler, Roona, et al., 2000; White and Pitts, 1998) and a set of studies that ana- lyzed mediators of the effects of these programs. Their synthesis led to six conclusions about effective programs. First, programs that involve interac- tions among participants and encourage them to learn drug refusal skills are more effective than noninteractive programs. Second, interventions that focus on direct and indirect (e.g., media) influences on use of drugs appear to be more effective than those that do not focus on social influences.

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8 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 7-2 Penn Resiliency Program: A Promising Universal Intervention to Prevent Depression The Penn Resiliency Program (PRP) strives to prevent depression by teach- ing middle school students to think flexibly and accurately about the challenges and problems they confront. Students learn, for example, about the links among beliefs, feelings, and behaviors and how to challenge negative thinking by evaluat- ing the accuracy of beliefs and generating alternative interpretations. The original evaluation of the program (Gillham, Reivich, et al., 1995) found that it halved the rate of moderate to severe symptoms among youths in a predominantly middle- income white sample. Another study (Jaycox, Reivich, et al., 1994) found that depressive symptoms were significantly reduced and classroom behavior was significantly improved in the treatment group compared with controls at posttest and six-month follow-up. The reduction in symptoms was most pronounced in the students who were most at risk. Positive results of PRP in preventing depressive symptoms have likewise been reported by Cutuli, Chaplin, and colleagues (2006) and Gillham, Hamilton, and colleagues (2006). The program has also been found to reduce anxiety (Roberts, Kane, et al., 2004). Similarly, students in a program patterned after PRP—the Penn Optimism Program—experienced decreased depressive symptoms relative to controls (Yu and Seligman, 2002). On the other hand, a study of a culturally tailored version of PRP with low- income minority middle school students had mixed results. The program had beneficial immediate and long-term effects on depressive symptoms for Latino children, but no clear effects for African American children (Cardemil, Reivich, and Seligman, 2002). Pattison and Lynd-Stevenson (2001) and Roberts, Reivich, and colleagues (2004) failed to replicate the findings reported by Gillham and colleagues (1995). These authors also found that a similar intervention—the Penn Prevention Program—showed no evidence of reducing depressive symptoms in youths, although Roberts, Kane, and colleagues (2004) noted that the intervention group reported less anxiety. Third, programs that emphasize norms for and a social commitment to not using drugs are superior to those without this emphasis. Fourth, adding community components to school-based programs appears to add to their effectiveness (see also Biglan, Ary, et al., 2000). Fifth, use of peer leaders may enhance short-term effectiveness (see also Gottfredson and Wilson, 2003). Sixth, adding training in life skills to that in social resistance skills may increase program effectiveness (see also Faggiano, Vigna-Taglianti, et al., 2005). A meta-analysis to assess potential moderators of program effectiveness by Gottfredson and Wilson (2003) determined that programs that can be delivered primarily by peer leaders have increased effectiveness. An analysis by Faggiano, Vigna-Taglianti, et al. (2005) found that the most effective

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 PREVENTION OF SPECIFIC DISORDERS BOX 7-3 Preventive Interventions Designed for Families with Parental Depression Two preventive interventions are aimed at providing education and support to families facing depression, helping them understand the illness and the value of obtaining treatment, and improving their capacity to reflect and solve problems together. One intervention involves two lectures followed by a group discussion with parents only. The other—the Family Talk Intervention—is clinician-facilitated; it consists of five to seven sessions (clinician-centered) that include discussion of the history of the illness and psychoeducation for the parents, meeting with the children (ages 8-14 at the time of enrollment), a family meeting planned and conducted by parents with the clinician’s help, and follow-up over several years. In a randomized efficacy trial of these two interventions, significantly more children in the Family Talk group reported gaining a better understanding of parental affec- tive illness as a result of their participation in the intervention. These results were sustained during the year following the intervention (Beardslee, Salt, et al., 1997; Beardslee, Versage, et al., 1997; Beardslee, Wright, et al., 1997). For long-term follow-up, the researchers followed 105 families. Analysis of the entire sample 2.5 years after enrollment showed sustained gains for both sets of intervention groups, with an increase in the main target of intervention—understanding in the children—as well as sustained changes in attitudes and behaviors in the parents; however, the improvement was significantly greater in the Family Talk group. There was an overall effect in both groups of a reduction in depressive symptomatology (Beardslee, Gladstone, et al., 2003). In the most recent follow-up, 4.5 years after enrollment, the same effects were found (Beardslee, Wright, et al., 2008). Also, both intervention groups showed an overall decline in depressive symptomatol- ogy, an increase in family functioning, and better recognition of when youngsters became depressed (Beardslee, Wright, et al., 2008). In another trial, these interventions were adapted for use with inner-city single- parent minority families (Podorefsky, McDonald-Dowdell, and Beardslee, 2001). The intervention proved safe and feasible, and there was more change in the families receiving the clinician approach than the lecture approach, although both interventions showed gains. The interventions have also been adapted for use with Hispanic families, and an open trial has demonstrated that they are safe and feasible and lead to significant gains for both parents and children, with stronger effects in the parents (D’Angelo, Llerena-Quinn, et al., in press). Additionally, the principles of the Family Talk intervention have been applied in a program to help teachers develop skills to deal with depressed parents in Head Start and Early Head Start (Beardslee, Hosman, et al., 2005; Beardslee, Ayoub, et al., in press). Family Talk is now being used in a number of country-wide efforts to develop programs for children of the mentally ill (see Box 13-1 in Chapter 13).

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200 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS programs are those focused on life and social skills. Skills-based programs increased drug knowledge, decision-making skills, self-esteem, and peer pressure resistance and were effective in deterring early-stage drug use. Derzon, Sale, and colleagues (2005) report on an analysis of a 46-site, five-year evaluation of school- and community-based substance abuse pre- vention programs that included behavioral skills programs, information- focused programs, recreation-focused programs, and affective programs. Using a meta-analytic technique to project potential impact by accounting for methodological and procedural differences, they calculated a mean adjusted effect size of 0.24 for decreasing 30-day substance use (tobacco, alcohol, and marijuana). Life Skills Training (see Box 7-4) is one of the most prevalent sub- stance use prevention curricula in the nation’s public schools and has been endorsed as a model program by both the Blueprints for Violence Preven- tion and the Surgeon’s General’s Youth Violence Report. Another successful alcohol, tobacco, and marijuana preventive intervention for middle school students is Project ALERT (see Box 7-5). The Drug Abuse Resistance Edu- cation (DARE) Program, based primarily on scare tactics, has been found BOX 7-4 Life Skills Training: A Universal Substance Use Prevention Program The current goal of the Life Skills Training (LST) Program (Botvin, 1996, 2000) is providing adolescents with the knowledge and skills needed to resist social influences to use cigarettes, alcohol, and other drugs, as well as reducing potential motivations to use these substances by increasing general personal and social competence (Botvin, 1986). Middle (or junior high) school students attend 15 45-minute class periods during or after school, with 10 booster class periods in the second year, 5 booster class periods in the third year, and optional violence prevention units. Botvin and colleagues evaluated LST in a three-year randomized controlled trial of predominantly white seventh grade students from 56 schools. Significant prevention effects were found for cigarette smoking, marijuana use, and immoderate alcohol use. Prevention effects were also found for normative expectations and knowledge concerning substance use, interpersonal skills, and communication skills. Three years later, approximately 60 percent of the initial seventh grade sample was surveyed again during a long-term follow-up study (Botvin, Baker, et al., 1995; Botvin, Griffin, et al., 2000). Significant reductions were found in both drug and polydrug use. Positive effects have also been found for a version of LST modified for minority studies (Botvin, Griffin, et al., 2001) and for an intervention combining LST and the Strengthening Families Program, which is described in Chapter 6 (Spoth, Redmond, et al., 2002; Spoth, Clair, et al., 2006). The benefits of LST have been reported to exceed its costs (Aos, Lieb, et al., 2004).

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20 PREVENTION OF SPECIFIC DISORDERS BOX 7-5 Project ALERT: A Middle School Substance Abuse Prevention Curriculum Project ALERT seeks to motivate middle school students not to use alcohol, tobacco, or marijuana and to impart skills needed to translate that motivation into effective resistance behavior. The curriculum includes lesson plans, handouts, interactive videos, posters, unlimited access to online training and resources, toll- free phone support, an ongoing ALERT Educator newsletter, and unlimited ability to download additional copies of lesson plans. The first evaluation of Project ALERT, conducted in the late 1980s, showed positive results in terms of drug use and associated cognitive risk factors (Ellickson and Bell, 1990). A second large-scale randomized controlled trial found similar results (Ellickson, McCaffrery, et al., 2003; Ghosh-Dastidar, Longshore, et al., 2004). On the other hand, a randomized, two-cohort longitudinal evaluation of the program found no positive effects, although this may have been due to implemen- tation differences (St. Pierre, Osgood, et al., 2005). The program is among the substance abuse prevention programs for which Aos, Lieb, and colleagues report that benefits exceed costs (2004). Project ALERT has evolved over time into a combined middle school and high school curriculum called ALERT Plus, which extends the basic curriculum to ninth grade with five booster lessons to help sustain the program’s positive effects. Longshore, Ellickson, and colleagues (2007) found weak results for Project ALERT in a randomized controlled field trial of the intervention with ninth grade at-risk adolescents. in multiple trials to be ineffective in its original form; a modified version is currently being tested. College Interventions Targeting Prevention of Alcohol and Drug Use and Abuse The evidence on alcohol and drug abuse prevention in colleges is lim- ited and inconclusive because, although many colleges have such programs, very few studies have evaluated them (Larimer, Kilmer, and Lee, 2005). More robust evaluation has been done of interventions focused on reducing drinking among college students. Carey, Scott-Sheldon, et al. (2007) report on a meta-analysis of 62 interventions. They found that, although on aver- age the interventions reduced alcohol consumption both immediately and at follow-up, the majority of studies failed to produce a significant effect. Variables associated with positive outcomes include motivational interview- ing (MI, a nonconfrontational approach to asking students to describe their

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20 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS randomized first or second grade students to the Raising Healthy Children intervention or a no-intervention group. At 18-month follow-up, program participants had higher teacher-rated academic performance and commit- ment to school, lower antisocial behavior, and higher social competency. Participants also showed less increase in the use of alcohol and marijuana in their middle school years (Brown, Catalano, et al., 2005). Similarly, in a meta-analytic review of 237 school-based mental health promotion programs, Durlak, Weissberg, and colleagues (2007) reported improvements in aspects of positive development (e.g., social-emotional skills, prosocial norms, school bonding, positive social behavior), as well as reductions in problem outcomes (e.g., aggressive behavior, internalizing symptoms, substance use). Kraag, Zeegers, and colleagues (2006) reviewed 19 trials of school-based programs that teach coping skills or stress man- agement through relaxation training, social problem solving, or social adjustment and emotional self-control. Although there was significant het- erogeneity in methodological quality, they found large pooled effect sizes for both enhanced coping skills and reduced stress symptoms. A recent evaluation by the RAND Corporation of a widely imple- mented after-school program, Spirituality for Kids, demonstrated a causal link between spiritual development and resilience. In a randomized trial involving 19 program sites, the program showed medium to large effects on positive behaviors, such as adaptability and communication, and small to medium effects on behavioral problems, such as attention problems, hyperactivity, and withdrawal (Maestas and Gaillot, 2008). Embry (2004) has suggested that the dissemination of a set of simple behavior-influence procedures, or “kernels,” would be helpful for parents, teachers, health care providers, and youth workers in fostering positive development among children and adolescents. Examples include praise notes (Gupta, Stringer, and Meakin, 1990; Hutton, 1983; Kelley, Carper, et al., 1988; McCain and Kelley, 1993), peer-to-peer tutoring (Greenwood, 1991a, 1991b), the Beat the Timer game (Adams and Drabman, 1995), and some of the skills that are used in parent–child interaction therapy (Eyberg, Funderburk, et al., 2001) and other caregiver training approaches. Others have similarly called for the study of core components of programs to facilitate their implementation in schools and other community settings (e.g., Greenberg, Feinberg, et al., 2007). Discerning generic principles that are common to diverse interventions could foster their broader use. Illustratively, because they achieve their preventive effects through promotion of family and child competencies, several programs discussed earlier in this report, including the Promoting Alternative Thinking Strate- gies (PATHS) curriculum (see Box 6-7), Fast Track (see Box 6-9), and Life Skills Training (see Box 7-4), as well as the Big Brothers Big Sisters Program (see Box 7-6) are frequently cited as successful promotion and prevention

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2 PREVENTION OF SPECIFIC DISORDERS BOX 7-6 Big Brothers Big Sisters Big Brothers Big Sisters is a community-based mentoring program that matches an adult volunteer (Big Brother or Sister) to a child ages 6-18 from a single-parent household (Little Brother or Sister), with the expectation that a supportive rela- tionship will solidify. The match is well supported by mentor training and ongoing supervision and monitoring by professional staff. An experimental design using random assignment was used to evaluate the Big Brother Big Sisters Program at eight sites across the country (Grossman and Tierney, 1998; Tierney, Grossman, and Resch, 1995). This study, although limited by the lack of long-term follow-up data after the 18-month intervention period and little information about site-level variability, had several positive findings. Youth in the treatment group (including both those who received a mentor and those who did not) had higher grade point averages, attended school more often, and reported better parental relationships and more parental trust despite lack of improvement in other related areas. They were less likely to initiate drug and alcohol use than those in the control group and also reported hitting others less often. Aos, Lieb, and colleagues (2004) cite Big Brothers Big Sisters as a mentoring program whose benefits exceed its costs. programs; they have also been recommended by Blueprints for Violence Prevention. Lifestyle Factors That Promote Mental Health and Prevent Mental, Emotional, and Behavioral Disorders Evidence from a small but growing set of observational and interven- tional studies indicates that modifications in a number of lifestyle factors, including sleep, diet, activity and physical fitness, sunshine and light, and television viewing, can promote mental health. Of these factors, the oppor- tunity is perhaps strongest for the salutary effects of adequate sleep and certain nutritional elements, such as adequate iron content in the diet. In many cases, intervention studies related to lifestyle factors have documented physical health benefits. Given the strong connections between physical and mental health, improvements in both may be achievable using common approaches. Attempts to modify lifestyle factors can appropriately be centered on families and the activities of the medical care community, promoted in the context of schools and community organizations, or accomplished through policy decisions. It should be noted that in many families, there are substan- tial barriers to promotion and prevention related to lack of knowledge, as

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22 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS well as factors that interfere with healthy decisions, such as poverty, neigh- borhood stresses, family tensions, and a general lack of child supervision. While there is a commonsense element to interventions aimed at improv- ing modifiable lifestyle factors, future efforts must rigorously document the promotion and prevention outcomes of their adoption. Promotion of mental health early in young people’s lives using such universal strategies that are feasible, inexpensive, and scientifically compelling holds great promise. Sleep Sleep deprivation and sleep-related breathing disorder (SBD) are linked to emotional and behavioral problems that include hyperactivity, inat- tention, impulsivity, mood lability, and aggression (Institute of Medicine, 2006c; Rosen, Storfer-Isser, et al., 2004; Wolraich, Drotar, et al., 2008). Hyperactivity and attention disorders are associated with two other sleep disorders—restless leg syndrome and periodic limb movement disorders (Chervin, Hedger Archbold, et al., 2002). Given that 20 percent or more of children have sleep problems, the contribution of SBD and other sleep problems to behavioral disorders is potentially enormous, though largely underrecognized. Interventions to improve sleep duration and quality must be rigorously assessed to deter- mine their potential for improving emotional and behavioral outcomes. For example, a program to screen all children in primary care based on a history of snoring, interrupted sleep, and insufficient hours of sleep could be followed by a behavioral assessment using validated instruments and behav- ioral interventions as indicated. Studies are needed to demonstrate that the treatment of obstructive sleep apnea with tonsillectomy and adenoidectomy or other measures reduces the occurrence of behavioral consequences. A more general proposed approach to healthy sleep is the establishment of a multimedia public education campaign targeting specific populations, such as children, their parents, teachers in preschool and elementary school, col- lege students, and young adults (Institute of Medicine, 2006c). The intent of such a campaign would be awareness concerning the consequences of insufficient or disrupted sleep, leading to identification of these problems and reestablishment of healthy sleeping patterns. Diet and Nutrition Adverse emotional and behavioral outcomes for children have long been linked to dietary factors. However, many suggested nutritional inter- ventions have little or no evidence base. Prenatal nutrition was addressed in Chapter 6. Postnatal nutrition factors include hunger, undernutrition, and failure to thrive, which have been linked to cognitive and behavioral

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2 PREVENTION OF SPECIFIC DISORDERS consequences (Dykman and Casey, 2003). Other factors that may be more modifiable include knowledge about optimal food intake and content, which can be addressed with education. Breastfeeding has been studied extensively concerning its relevance to emotional and behavioral health. On the one hand, mounting evidence sug- gests that breastfeeding can contribute to enhanced cognitive capabilities independently of confounding factors (Kramer, Aboud, et al., 2008). While the IQ effect is modest in most studies, intelligence is a protective factor for MEB disorders and related problems. On the other hand, the weight of evidence at this time does not support superior behavioral outcomes for children who have been breastfed (Kramer, 2008). Based on current infor- mation, breastfeeding should be promoted for many reasons, but preven- tion of MEB disorders in childhood or in later life is not one of them. Avoidance of nutritional deficiencies is important for promotion of mental health. High on the list of critical nutritional elements is iron. Children shown to have severe chronic iron deficiency in infancy score lower on measures of mental and motor functioning and are rated by both parents and teachers after 10 years of follow-up as more problematic in the areas of anxiety, depression, social problems, and attention problems (Lozoff, Jimenez, et al., 2000). This study is one of several that suggests an important relationship between iron deficiency and subsequent behav- ior. A concern, of course, is that iron repletion does not reverse long-term adverse outcomes and that iron deficiency remains very common in the United States (e.g., Schneider, Fuji, et al., 2005). U.S. Hispanic children and overweight children are particularly vulnerable (Brotanek, Halterman, et al., 2005). Strategies for avoiding iron deficiency include iron supplementa- tion of exclusively breastfed babies (Dallman, Siimes, and Steckel, 1980), avoidance of prolonged bottle feeding (Brotanek, Halterman, et al., 2005), and routine testing of certain populations of infants for iron deficiency in the course of medical care. Given the magnitude of potential adverse out- comes, systematic efforts to inform parents of childbearing age about the importance of adequate iron intake for both mother and child should be adopted and sustained at the national level. Attention has been focused for the past decade or two on the omega-3 fatty acid content of prenatal maternal diets and diets for children post- natally. Low levels of DHA and EPA—omega-3 fatty acid products—and corresponding high levels of arachadonic acid have been shown in animal studies to be detrimental to brain development (Innis, 2008) and are related to indices of brain inflammation (Orr and Bazinet, 2008). Cognitive and some behavioral consequences of this imbalance have been described in animals and correlated with effects on cell membranes in the central ner- vous system (Mahieu, Denis, et al., 2008). In human studies, alterations in omega-3 fatty acid levels have been associated with cardiovascular disease;

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24 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS stroke; cancer; cognition problems; and a number of behavioral problems, including attention deficit disorders, depression, autism, and suicide. A number of randomized trials of omega-3 supplementation for mothers during gestation or for infants indicate benefits for cognitive and motor skills, including language development. These improvements could serve as protective factors for MEB disorders. Trials of the effects of omega-3 supplementation on aggression have also been conducted. Studies involv- ing children have had mixed results, with three studies demonstrating a reduction in some symptoms of ADHD and related problem behaviors (Richardson and Montgomery, 2005; Richardson and Puri, 2002; Sinn and Bryan; 2007); one showing a reduction in hostility and aggression, primar- ily among girls (Itomura, Hamazaki, et al., 2005); two showing no effect on aggressive or disruptive behavior (Hirayama, Hamazaki, and Terasawa, 2004; Voigt, Llorente, et al., 2001); and one finding only limited effective- ness (Stevens, Zhang, et al., 2003). While not yet conclusive, however, the available evidence warrants well-designed experimental trials of the impact of omega-3 in preventing depression and behavioral disorders involving aggression. The majority of randomized controlled trials of omega-3 supplementa- tion have focused on its use to treat adults with mental disorders. Although two recent meta-analyses report evidence for the potential value of omega- 3 supplementation, particularly for depression (Freeman, Hibbeln, et al., 2006; Lin and Su, 2007), another suggests that the effects are negligible (Appleton, Hayward, et al., 2006). All concur, however, regarding the troublesome variability of results; the heterogeneity and poor quality of many studies; and the need for large-scale, well-designed and -executed studies to permit conclusive statements. Other associations between dietary content and MEB disorders are focused on the potential effects of allergenic foods and large boluses of sugar on the occurrence of ADHD (Wolraich, 1998). More study in this area is warranted. Neurotoxins Exposure to neurotoxins, such as lead and mercury, is a significant risk during gestation (see Chapter 5). Postnatal exposures are also of con- cern. Blood levels of neurotoxins in childhood are correlated with cogni- tive deficits and MEB disorders, including ADHD and conduct disorder (Braun, Kahn, et al., 2006; Braun, Froehlich, et al., 2008). Evidence has accumulated that blood lead levels once thought to be safe (>10 mg/ml) can be detrimental to infants (Canfield, Henderson, et al., 2003). Protec- tion against exposure to lead, as well as other potential neurotoxins whose effects are not as well documented, is deserving of greater national atten-

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25 PREVENTION OF SPECIFIC DISORDERS tion, and demands the concerted efforts of medical caregivers, environment health specialists, community organizations, and lawmakers, as well as regulatory officials at all levels of government. Physical Fitness and Exercise Physical fitness and exercise are widely recognized as important modu- lators of stress, and there is some evidence of their effectiveness for the treatment of depression (Craft, Freund, et al., 2008). A meta-analysis of exercise interventions targeting depression and anxiety, primarily in college students, showed significant positive effects related to depression and posi- tive but not significant effects related to anxiety (Larun, Nordheim, et al., 2006). However, the 16 available trials were of low methodological quality. A clear relationship between physical fitness and exercise and the preven- tion of MEB disorders in children is even less well documented. Given the clear relationship between exercise and stress, however, both general and medical education for children and their families should include discussion of appropriate exercise and advocacy for overall family fitness. Television Viewing Extended television viewing has been linked to the occurrence of ADHD (Christakos, Zimmerman, et al., 2004) and limiting television time for children as a preventive measure has received increasing attention. The American Academy of Pediatrics recommends no television viewing for children under two years of age and no more than two hours a day there- after. Exposure of children to violence through television and other media has been linked to conduct problems in children and adolescents (Bushman and Huesmann, 2006; Huesmann, Moise-Titus, et al., 2003). Attempts to reduce exposure of children to violence have had very little effect on the content of entertainment programming, and management of this risk falls largely to in-home restriction. Sunlight Exposure to adequate sunlight and light in general may affect mental health. Vitamin D deficiency can occur because children today are out- side for shorter periods of time and are often protected by sunscreen. Vitamin D may have effects not only on bone mineralization, but also on immunity to infectious agents. Vitamin D plays an important role as well in brain development and function. Subtle effects of vitamin D deficiency on behavior have been suggested, but a causal relationship has not been firmly established (McCann and Ames, 2008). Whether prevention of vita-

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26 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS min D deficiency truly contributes to mental health in childhood deserves further study. Furthermore, limited exposure to light is related, in some individuals, to the occurrence of seasonal affective disorder. More brightly lit classrooms are associated with fewer classroom problems for children with ADHD (Kemper and Shannon, 2007). CONCLUSIONS AND RECOMMENDATIONS: CHAPTERS 6 AND 7 This and the preceding chapter have documented substantial progress since the 1994 IOM report in approaches to prevention in multiple develop- mental stages. The strength of evidence related to prevention of symptoms and incidence of externalizing disorders and problem behaviors has signifi- cantly increased, particularly through school-based interventions. There is emerging evidence that preventive interventions not only can reduce symp- tomatology, but also can reduce the number of new cases of depression. And there is promising evidence of the potential to intervene in the lives of young people in the early stage of schizophrenia, prior to full-blown disorder. Many programs that have been tested in multiple randomized con- trolled trials demonstrate efficacy, and an increasing number have dem- onstrated effectiveness in real-world environments. Increasing numbers of programs are culturally adapted and, while still relatively limited, some have been tested with multiple racial, ethnic, or cultural groups. It is no longer accurate to argue that emotional and behavioral problems cannot be prevented or that there is no evidence for the prevention of MEB disorders experienced during childhood, adolescence, and early adulthood. Conclusion: Substantial progress has been realized since 1994 in dem- onstrating that evidence-based interventions that target risk and protec- tive factors at various stages of development can prevent many problem behaviors and cases of MEB disorders. Interventions variously target strengthening families by modifying dis- cipline practices or parenting style; strengthening individuals by increasing resilience and modifying cognitive processes and behaviors of young people themselves; or strengthening institutions, such as schools, that work with young people by modifying their structure or management processes. Par- enting and family-based interventions have demonstrated positive effects on reducing risk for specific externalizing disorders, for multiple problem outcomes in adolescence, for reducing prevalence of diagnosed MEB disor- ders, and for reducing parenting and family risk factors. Conclusion: Interventions that strengthen families, individuals, schools, and other community organizations and structures have been shown to

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27 PREVENTION OF SPECIFIC DISORDERS reduce MEB disorders and related problems. Family and early child- hood interventions appear to be associated with the strongest evidence at this time. Interventions based in schools have demonstrated positive effects on violence, aggressive behavior, and substance use and abuse. Emerging evi- dence has indicated the potential for a positive impact of some of these interventions on academic outcomes. Communities have a role in support- ing preventive interventions and in developing responses that address com- munity needs and build on community needs. Conclusion: Community-based organizations, particularly schools and health care providers, can help prevent the development of MEB dis- orders and related problems. Although an increasing number of interventions have shown positive results related to reductions in the incidence or prevalence of MEB disor- ders, most measure highly relevant risk and protective factors but do not measure disorders per se. Conclusion: Preventive interventions can affect risk and protective factors strongly associated with MEB disorders. Future research must determine the full impact of these interventions on MEB disorders. Preventive interventions have increasingly demonstrated positive effects on multiple outcomes, but the range of outcomes assessed is also limited. The same type of intervention may demonstrate positive effects on differ- ent outcomes, given the limited nature of the outcomes assessed. Similarly, although academic outcomes are likely to be important to schools consider- ing adoption of preventive interventions, because there is some indication of positive effects on academic achievement, this has been assessed in only a few studies. Inclusion of a broader range of outcomes could help in the identification of potential iatrogenic effects that can meaningfully inform the development of future interventions. Recommendation 7-1: Prevention researchers should broaden the range of outcomes included in evaluations of prevention programs and policies to include relevant MEB disorders and related problems, as well as common positive outcomes, such as accomplishment of age- appropriate developmental tasks (e.g., school, social, and work out- comes). They should also adequately explore and report on potential iatrogenic effects.

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28 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Although there are now multiple, well-tested interventions, the effect sizes for most interventions are small to modest. Similarly, though several studies have now demonstrated results with strong empirical designs and statistical techniques, meta-analyses consistently highlight the methodologi- cal weaknesses of many studies. As discussed in Chapter 10, this is not because of a lack of appropriate methodological techniques. There is a convergence among both meta-analyses and individual studies suggesting that interventions are more effective for participants with elevated risk, including for participants in many universal interventions. However, most interventions have been tested with a single cultural group, and few have been tested in community-wide interventions that reach large numbers of at-risk youth. Continued rigorous research is needed to improve the reach of current interventions and to expand interventions that are culturally relevant and responsive to community priorities (see Chapter 11). Conclusion: Although evidence-based interventions are now available for broad implementation in some communities, there is a need to increase the effectiveness of prevention programs and to develop inter- ventions that reach a larger portion of at-risk populations. Recommendation 7-2: Research funders should strongly support research to improve the effectiveness of current interventions and the creation of new, more effective interventions with the goal of wide-scale implementation of these interventions. Mass media and the Internet present a potential opportunity to reach large numbers of young people with readily disseminable interventions. Although the currently available evidence does not support particular inter- ventions, this is an area that warrants additional research. Mass media also offers the potential to address concerns related to stigma that serve as a barrier to prevention. Recommendation 7-3: Research funders should support research on the effectiveness of mass media and Internet interventions, including approaches to reduce stigma. Although the research base of preventive interventions has expanded significantly, there are several groups or settings that have not been repre- sented in this expansion. With the exception of college populations, very little research has been done related to young adulthood. Adolescence is also less well represented than earlier developmental periods. In addition, there has been limited research following young people across develop- mental stages. Although there is converging evidence that approaches that

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2 PREVENTION OF SPECIFIC DISORDERS combine multiple interventions, such as family and school interventions, have greater effects, this is a relatively new area of inquiry. Recommendation 7-4: Research funders should address significant research gaps, such as preventive interventions with adolescents and young adults, in certain high-risk groups (e.g., children with chronic diseases, children in foster care) and in primary care settings; interven- tions to address poverty; approaches that combine interventions at mul- tiple developmental phases; and approaches that integrate individual, family, school, and community-level interventions. In addition, as discussed in the chapters that follow, achieving the wide- spread benefits of evidence-based preventive interventions will also require further research on how to train those who implement interventions, how to influence organizations to adopt evidence-based interventions and to implement them with fidelity, and establishing an infrastructure with the capacity to implement and evaluate proven approaches. These problems might seem to be political and beyond the purview of public health and the behavioral sciences. However, policy decisions and the public support needed to influence those decisions are matters of human behavior. Just as a behavior like cigarette smoking is seen as something to change because it is a risk factor for cancer and heart disease, the lack of public understanding and support for prevention can be seen as a risk factor for societal failure to prevent problem development in childhood and adolescence. Research on how to generate public support for the implementation of evidence-based practices is a next logical step in the centuries-long struggle of the public health community to improve human well-being.

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