13
Toward an Improved Approach to Prevention

The preceding chapters described the substantial scientific progress in the conceptualization, design, assessment, and evaluation of preventive intervention approaches for children, youth, and families since the 1994 Institute of Medicine (IOM) report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. There has been laudable progress in the science of mental health promotion and prevention of mental, emotional, and behavioral (MEB) disorders. It is now evident that the incidence of some of these disorders, such as depression, can be significantly reduced. There is also evidence to support multiple approaches aimed at strengthening individual, family, and community competencies that have been causally linked to mental, emotional, and behavioral health, either by reducing malleable risk factors for disorders or enhancing protective factors. We call on the nation to put this knowledge into practice. At the same time, as discussed in earlier chapters, we have identified significant gaps in current knowledge and key areas in which more research and infrastructure changes are needed to fully release the potential to significantly reduce MEB disorders among young people.

The promise of preventing MEB disorders, evident in the research over the past several decades, has prompted numerous federal agencies and stakeholder organizations to encourage grantees and community organizations to adopt evidence-based interventions. The National Institutes of Health (NIH) and other agencies have funded multiple parallel research projects. It is now time for a coordinated, strategic approach that brings together the range of resources, provides consistent advice to communities, and strategically aligns research priorities to needs. As discussed in



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13 Toward an Improved Approach to Prevention T he preceding chapters described the substantial scientific progress in the conceptualization, design, assessment, and evaluation of preven- tive intervention approaches for children, youth, and families since the 1994 Institute of Medicine (IOM) report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. There has been laudable progress in the science of mental health promotion and prevention of mental, emotional, and behavioral (MEB) disorders. It is now evident that the incidence of some of these disorders, such as depression, can be significantly reduced. There is also evidence to support multiple approaches aimed at strengthening individual, family, and community competencies that have been causally linked to mental, emotional, and behavioral health, either by reducing malleable risk factors for disorders or enhancing protec- tive factors. We call on the nation to put this knowledge into practice. At the same time, as discussed in earlier chapters, we have identified significant gaps in current knowledge and key areas in which more research and infra- structure changes are needed to fully release the potential to significantly reduce MEB disorders among young people. The promise of preventing MEB disorders, evident in the research over the past several decades, has prompted numerous federal agencies and stakeholder organizations to encourage grantees and community organi- zations to adopt evidence-based interventions. The National Institutes of Health (NIH) and other agencies have funded multiple parallel research projects. It is now time for a coordinated, strategic approach that brings together the range of resources, provides consistent advice to communi- ties, and strategically aligns research priorities to needs. As discussed in 77

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78 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS the preceding chapter, although there are a number of interagency efforts, they tend to be focused on a single program or an isolated issue related to prevention rather than on a holistic vision. Historically, prevention has received far less attention than treatment in either mental health or physical health. A fundamental paradigm shift needs to occur. The substantial prog- ress in prevention science summarized in this report calls for the adoption of a prevention perspective and a resolve to test and determine the most promising application of specific evidence-based preventive approaches. Recommendation 13-1: The federal government should make the healthy mental, emotional, and behavioral development of young people a national priority, establish public goals for the prevention of specific MEB disorders and for the promotion of healthy develop- ment among young people, and provide needed research and service resources to achieve these aims. Accomplishing this will require a more systematic approach at multiple levels—national, state, and local—and continued progress in prevention research. A NEW NATIONAL DISCOURSE The 1994 IOM report strongly recommended the creation of a mecha- nism to coordinate research and services across federal departments, sug- gesting the creation of a national scientific council as one model, possibly under an office in the White House. A variety of national-level groups (New Freedom Commission on Mental Health, 2003; U.S. Public Health Service, 2000) have concurred in saying that the nation should consider a strong, broad-based public health infrastructure to both monitor and deploy resources in mental and physical health care. Current federal policy, research, and practice relevant to prevention of MEB disorders are fragmented across a wide variety of agencies. Research on prevention (and treatment) is organized to address individual disorders and problems. However, evidence that common risk factors lead to multiple interrelated disorders and problems, coupled with significant evidence on possible approaches to mitigating these factors, calls for a concerted stra- tegic, national effort to coordinate research, policy, and practice aimed at preventing MEB disorders and promoting healthy development. This effort would build on the significant evidence currently available and continue to be informed by new research as it emerges. Recommendation 13-2: The White House should create an ongoing mechanism involving federal agencies, stakeholders (including profes-

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7 TOWARD AN IMPROVED APPROACH sional associations), and key researchers to develop and implement a strategic approach to the promotion of mental, emotional, and behav- ioral coordinating and health and the prevention of MEB disorders and related problem behaviors in young people. The U.S. Departments of Health and Human Services, Education, and Justice should be account- able for coordinating and aligning their resources, programs, and initia- tives with this strategic approach and for encouraging their state and local counterparts to do the same. One of the first tasks would be to establish specific, measurable goals for the next 10 years (see Recommendation 13-1) and a strategy to sup- port the accomplishment of goals. In establishing goals, consideration should be given to the prevalence of disorders, costs associated with those disorders, and the strength of the evidence that the disorder is prevent- able. Promising areas include the prevention of depression, substance abuse, and conduct disorder. Existing surveys provide data on substance use and adolescent (ages 12-17) depression. The Federal Interagency Forum on Child and Family Statistics has recently added an indicator related to the prevalence of depression among youth in its Key National Indicators of Well-Being report and includes indicators of alcohol and drug use. The forum has also identified the need for measures of positive behaviors.1 This could serve as a starting point. Similarly, consideration should be given to the approaches that both promote healthy development and have the greatest potential to affect multiple disorders, such as those aimed at strengthening families. In developing the strategy, priority should be placed on educating the public on the potential to improve support of the nation’s young people, including efforts to reduce the stigma associated with mental, emotional, and behavioral problems, and on engaging relevant professional and inter- governmental organizations in a coordinated approach to improving sup- port systems for young people and their families. Development of the strategy would have multiple components: • Identify and evaluate all federal programs and policies to determine which ones should be recommended to states and communities based on an agreed standard of evidence; these programs should be given highest priority for dissemination. • Create networks of prevention delivery programs involving schools, primary health care, behavioral health care, and other community- based programs that are sites for investigation and innovation 1 See http://www.childstats.gov.

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80 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS for both family-centered preventive intervention and individual- centered intervention. • Explore the possibility of set-asides or targeted funding for promotion and prevention activities, similar to the set-aside proposed for the Mental Health Services Block Grant (see Recommendation 12-1). • Consult with leading researchers, major stakeholder and profes- sional organizations, and constituency groups in developing priori- ties, goals, and a shared action agenda. • Coordinate with relevant foundations to identify priority part- nerships aimed at better understanding the implementation of evidence-based programs, possibly through the Child Mental Health Foundations and Agencies network, a collaborative of public and private agencies and foundations interested in issues of child development and public policy. • Coordinate with NIH on the development of a 10-year research agenda (see Recommendation 13-5) and plan, organize, and sup- port further research, led by NIH: — To further examine the impact of programs and policies to determine the extent to which they prevent the development of problems, promote mental health, or both. That research should assess the impact of interventions on multiple disorders and problems. — To experimentally evaluate strategies for getting effective pro- grams and policies widely and effectively adopted. • Oversee development of approaches to monitor the prevalence of disorders and key risk and protective factors, as well as relevant service use across a range of delivery systems (see Recommenda- tions 2-1 and 2-2). • Identify specific opportunities to braid the funding of research and practice so that the impact of programs and practices that are being funded by service agencies, such as the Substance Abuse and Men- tal Health Services Administration (SAMHSA), are experimentally evaluated through research funded by such agencies as NIH or the Institute of Education Sciences (IES) (see Recommendation 12-2). • Consider the potential to develop a standardized system to measure core promotion and prevention outcomes that could be used and adapted by states and communities across the country to monitor performance, potentially building on existing community monitoring systems. • Oversee the development and implementation of consistent, rigor- ous standards of evidence for endorsement of prevention programs (see Recommendation 12-4).

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8 TOWARD AN IMPROVED APPROACH Both service and research components of the relevant agencies should be involved. These include, in the U.S. Department of Health and Human Services, NIH, SAMHSA, the Health Resources and Services Adminis- tration, the Administration for Children and Families, the Centers for Medicare and Medicaid Services, the Centers for Disease Control and Pre- vention, and the Office of the Assistant Secretary for Planning and Evalua- tion; in the U.S. Department of Education, IES and Safe Schools; and in the U.S. Department of Justice, the Office of Juvenile Justice and Delinquency Prevention and the National Institute of Justice. The need for high-level coordination across multiple agencies, the broad implications of healthy development for multiple components of society, and the significant cost associated with MEB disorders call for ongoing White House involvement. The White House has played a leadership role in other related issues, such as violence against women, mental health policy (the New Freedom Com- mission), strengthening youth, and drug control policy. A new, ongoing interagency mechanism focused on the emotional and behavioral health of young people could build on and extend the current White House effort to help America’s youth. This current effort, a “nationwide effort to raise awareness about the challenges facing our youth, particularly at-risk boys, and to motivate caring adults to connect with youth in three key areas: family, school, and community,”2 already recognizes many of the core find- ings outlined in this report. The specific mechanism could take many forms, including a new White House office, an ongoing commission, or a White House–led strategic coor- dinating group. Regardless of the form it takes, it should have adequate authority to direct agency resources in a coordinated manner, facilitate a paradigm shift that emphasizes promotion and prevention, and have a long-term mandate. Just as there have been significant advances in prevention science in the past 15 years, it is highly likely that there will be considerable progress in the next 15 years with the development of new, more refined prevention strategies. The nation should have a mechanism in place to benefit from rapid deployment of these advances. The creation of an ongoing strategic mechanism to coordinate federal efforts will facilitate consideration of how these advances are best applied. A major need for the immediate future is to systematically study how to effectively translate these strategies to broad-based prevention programs and to identify mechanisms for federal support of community and state efforts. The time is ripe for interventions to be delivered and tested in primary care, in the mental health care sector, in schools, in community organizations, and in families. Mental health efforts are often fragmented and of uneven quality for 2 See http://www.helpingamericasyouth.gov/whatishay.cfm.

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82 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS children, youth, and families, as they are for adults (Institute of Medicine, 2006b) and for physical health care (Institute of Medicine, 2001). In the long run, consideration needs to be given to an effective, broad-based, strong public health network that can provide adequate data to moni- tor progress and support the delivery of high-quality preventive services focused on mental and physical health in a variety of sectors. Linked services for the promotion of mental and physical health can respond to the growing recognition that mental health is dependent on good physical health and vice versa. The committee was struck by the pervasive role played by poverty in development of a range of MEB disorders and related problems. Similarly, the health care system in the United States, which limits access to and quality of care for many of the most poor and disenfranchised, compli- cates effective prevention. National attention should be paid to narrowing income and health care disparities as a fundamental part of the promotion of mental health and prevention of MEB disorders. DEVELOPING STATE AND LOCAL SYSTEMS Prevention science has identified the major malleable risk factors for the development of most MEB disorders and related problems. The number of efficacy trials and the experimental and statistical methods needed to make reliable conclusions have exploded since 1994. Numerous interventions have been tested in two or more randomized controlled trials, and several have been tested in multiple U.S. communities or implemented nationwide in European countries. The inability of the mental health care system to respond to the demands for treatment is well documented. Many young people receive treatment in systems outside the formal mental health care system, such as schools, primary medical care, child welfare, and criminal justice. Not all cases of MEB disorder can be prevented, but a concerted effort to determine the proportion of such disorders that can be prevented is now possible. Shift- ing the focus toward prevention may help alleviate pressures on treatment resources; this would need to be empirically tested through community- or statewide implementation of prevention. The mental, emotional, and behavioral health of young people can- not, and should not, be the responsibility of the mental health care system alone. Improvements or potential savings from effective prevention inher- ently benefit systems other than, or in addition to, the system implementing an intervention. Similarly, the failure of one system involved in a young person’s life can have costs for another. For example, there is evidence that improving social and emotional functioning improves academic outcomes. Interventions involving both families and schools seem to have a high level

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8 TOWARD AN IMPROVED APPROACH of success. Increasingly, parents are bringing their children to physicians’ offices with behavioral concerns. Schools and primary care settings may be less stigmatizing for children and families and may enable exploration of emotional and behavioral health issues more openly than a mental health setting. Successes in other areas, such as prevention of smoking, suggest that approaches that involve complementary components at multiple levels are needed. Involving multiple community systems has the potential to leverage resources and implement approaches that support young people throughout their development rather than only in a particular grade or a particular school. Multiple federal programs have required state and local grantees to implement evidence-based programs. This has both raised awareness regarding evidence-based programs and created a missed opportunity to learn about effective implementation and how adaptation of programs to local circumstances might affect outcomes. This information is needed not only at the national level, but also to inform the community on progress, determine changes needed, and sustain interest in community-wide efforts. Creating systems that support the implementation of preventive interven- tions, allow their continuous improvement, and facilitate the introduction of new approaches, while evaluating results, should complement national research and planning efforts. Recommendation 13-3: States and communities should develop net- worked systems to apply resources to the promotion of mental health and prevention of MEB disorders among their young people. These sys- tems should involve individuals, families, schools, justice systems, health care systems, and relevant community-based programs. Such approaches should build on available evidence-based programs and involve local evaluators to assess the implementation process of individual programs or policies and to measure community-wide outcomes. Both the identification of problems and resources and the development of solutions will vary by community. However, monitoring systems, a key component of public health, should be integral to any state or community- wide system in order to track the incidence and prevalence of MEB dis- orders as well as key risk and protective factors and provide information needed to guide efforts. Many states are implementing monitoring sys- tems similar to available national surveys, such as Monitoring the Future, the Youth Risk Behavior Survey, and the National Household Survey of Drug Use and Health (Mrazek, Biglan, and Hawkins, 2004; Boles, Biglan, and Smolkowski, 2006). These surveys provide estimates of substance use and, in some cases, data on adolescents’ self-reported antisocial behavior

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84 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS and high-risk sexual behavior. States and communities need to develop monitoring systems that are capable of providing data on other targeted disorders. In addition, these systems can be used to mobilize support for community-based prevention efforts. For example, annual data on adoles- cent depression could be used to motivate support for the implementation of evidence-based depression preventions. This requires, however, that data be summarized and delivered to key target audiences in a timely, clear, and useful manner. Web-based systems for delivering this information show great promise (Mrazek, Biglan, and Hawkins, 2004). Ideally, a template for a community monitoring system would be developed at the national level and available to all communities, and the national system recommended by the committee (see Chapter 2) would adopt use of unique identifiers to enable use by state and local networks. MONITORING, FUNDING, AND TRAINING National and state systems will have to be supported by adequate monitoring systems, funding, and trained personnel. In addition, rigorous standards must be developed and implemented to provide clear guidance to states and communities on the readiness for implementation of specific interventions. The committee’s recommendations call for action in each of these areas by federal agencies and by relevant training programs. Monitoring system. There is a need to develop approaches to • report on the prevalence of disorders and key risk and protective factors and to report on the utilization of mental health care ser- vices across multiple service systems that work with young people (see Chapter 2). Standards. Federal and state agencies need to identify and prioritize • the use of evidence-based programs by applying scientific criteria to assess programs (see Chapter 12). Funding. Federal agencies need to increase resources to states and • local communities to implement approaches to prevention, ideally partnered with research funding, targeted to communities with greatest need (see Chapters 8, 11, and 12). Training. Guidelines, model training programs, and accredita- • tion standards are needed for training both researchers and prac- titioners on prevention of MEB disorders and promotion of mental health. Research training programs that facilitate creation of multi- disciplinary training teams will advance translational prevention research efforts aimed at integrating developmental neuroscience and preventive intervention research (see Chapters 5 and 12).

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85 TOWARD AN IMPROVED APPROACH REFINING AND EXPANDING PREVENTION RESEARCH Substantial progress has been made since the 1994 IOM report in iden- tifying mechanisms to affect risk or protective factors for MEB disorders, developing specific approaches to affect those factors, and strategies to pre- vent specific disorders, such as depression and substance abuse. However, despite the high prevalence of MEB disorders and the promise apparent from prevention research, research on prevention has not received attention or funding commensurate to that of treatment research. Recommendation 13-4: Federal agencies and foundations fund- ing research on the prevention of MEB disorders should establish parity between research on preventive interventions and treatment interventions. Multiple federal agencies, across several departments, fund research related to prevention. Research priorities differ across agencies, making it difficult to systematically identify and address new research needs. Con- tinued progress over the next decade and the nation’s ability to reduce the prevalence of disorders will require that efforts to implement what is cur- rently known are married with rigorous efforts to address gaps in research knowledge. Recommendation 13-5: The National Institutes of Health, with input from other funders of prevention research, should develop a compre- hensive 10-year research plan targeting the promotion of mental health and prevention of both single and comorbid MEB disorders. This plan should consider current needs, opportunities for cross-disciplinary and multi-institute research, support for the necessary research infrastruc- ture, and establishment of a mechanism for assessing and reporting progress against 10-year goals. Several specific recommendations related to gaps in research knowledge have been identified throughout the report and should be considered in development of this plan: Screening. Approaches needed to develop and test models for • screening in school and primary care settings (see Chapter 8). Intervention effectiveness. Development of new and more effective • interventions, as well as research aimed at replicating findings with a range of target populations and demonstrating outcomes over time, ideally across developmental phases (see Chapters 7 and 10).

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86 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Multi-institute collaborations. Collaborative funding of interven- • tions that target risk factors common to multiple disorders and assess multiple outcomes (see Chapters 4 and 12). Cultural relevance. Research on how interventions developed • with one cultural or ethnic group work with other groups (see Chapter 11). Economic analyses. Need for guidelines, measures, and funding for • economic analyses (see Chapter 9). Dissemination and implementation. Methodologies and strategies • for dissemination and implementation of preventive interventions, including research on (1) state- and community-wide implementa- tion, (2) alternative approaches to implementation that vary such factors as type of provider or training, (3) potential strategies for use of the mass media and Internet, and (4) identification of program components that might facilitate implementation (see Chapter 11). Competencies. Need for improved understanding of etiology and • development of competencies, their protective role, and develop- ment of measurement tools (see Chapter 4). Neuroscience and prevention. Approaches to linking findings from • brain research and research on gene–environment interactions with intervention research, to test hypotheses related to epigenetics and neuroscience, and development of guidelines on ethics of using individually identifiable information (see Chapter 5). Gaps in current research. Interventions for such groups as young • adults and young people with chronic health problems, in such set- tings as primary care, comprehensive interventions, and approaches to addressing poverty (see Chapters 6 and 7). To assist in the implementation of a prevention research agenda and to help distinguish prevention research from treatment research, this report calls on the prevention community to adopt a definition of prevention that focuses on populations that do not currently have a disorder, including three levels of intervention: universal (for all), selective (for groups or indi- viduals at greater than average risk), and indicated (for high-risk individuals with specific phenotypes or early symptoms of a disorder). However, it also calls on the prevention community to embrace mental health promotion as within the spectrum of mental health research. In addition, prevention researchers are advised to broaden the focus of their research to include consideration of cost-effectiveness and the impact of interventions on mul- tiple outcomes.

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87 TOWARD AN IMPROVED APPROACH ENVISIONING THE FUTURE The scientific foundation has been created for the nation to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and pro- ductive lives in caring relationships with others. Implementation of the recommendations of this report will move it firmly in the direction of such a society. This movement can be guided by a vision of what families, schools, neighborhoods, health care providers, and community organizations could be like. There would be a well-organized system of organizations, programs, and policies to ensure strong families and schools and nurturing neighbor- hoods. Young people would have access to high-quality, well-administered schools, access to health care and other community services, and healthy environments, activities, and food. The system would include the following elements specific to prevention: 1. Factors shown to improve the physical and mental health of chil- dren and their caregivers are explicitly addressed by the systems that provide services to them. Responsibility for and investment in interventions affecting children’s development and long-term futures is shared by multiple service systems, including education, child welfare, primary care, and mental health. 2. Families and children have ready access to the best available evidence-based preventive interventions, delivered in their own communities in a culturally competent and respectful (nonstigma- tizing) way. 3. Preventive interventions are provided as a routine component of school, health, and community service systems, reducing stigma to a minimum. 4. A well-organized public health monitoring system is in place at the national and community levels to track the incidence and preva- lence of MEB disorders in young people and used to appropriately direct resources as well as to monitor the cost and impact of pre- vention and treatment efforts. 5. Services are coordinated and integrated with multiple points of entry for children and their families (e.g., through schools, health care settings, and community-based organizations, such as youth centers and churches). 6. As further new discoveries, interventions, or adaptations occur, including such innovations as the use of the Internet for preventive purposes, these are incorporated into already existing networks for the delivery of services.

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88 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS 7. Families are informed that they have access to resources when they need them without barriers of culture, cost, or type of service. 8. Families and communities are partners in the development and implementation of preventive interventions and learn to manage their access and utilization of prevention services. 9. The development and application of appropriate preventive inter- vention strategies contribute to narrowing rather than widening health disparities. 10. Teachers, child care workers, health care providers, and other professionals who work with young people are routinely trained on approaches to support the behavioral and emotional health of young people and the prevention of MEB disorders. The type of system envisioned above, which routinely provides univer- sal interventions that support healthy development for all and systemati- cally identifies groups and individuals at greater risk to provide them with specific services, could result in very different outcomes for the nation’s young people. Table 13-1 illustrates what a system might look like at vari- ous developmental phases. International Perspectives The committee was impressed with evidence showing that some of the prevention advances being suggested for the United States are already in place in other developed nations. A comprehensive review of international policies and programs is outside the scope of this report. However, a brief discussion and a few examples illustrate that our recommendations are not merely utopian dreams, but rather a call for the nation to make available to children and families the types of services and initiatives that are already being implemented in other countries. Europe as a whole is working toward a comprehensive strategy on mental health, with a strong focus on mental health promotion and the prevention of MEB disorders (Jané-Llopis and McDaid, 2005). As this process unfolds, it could inform how the United States should integrate prevention into systems at the federal, state, and local levels while taking into account the distinct needs of different communities. At the World Health Organization Ministerial Conference on Mental Health in 2005, member states of the European Region endorsed a European Action Plan for Mental Health that includes the promotion of mental health and preven- tion of mental illness (World Health Organization, 2005). In support of the implementation of the action plan, the European Commission produced a Green Paper on Mental Health. This document outlined a framework to increase the coherence of health and nonhealth policies in support of mental

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8 TOWARD AN IMPROVED APPROACH TABLE 13-1 Examples of Potential Components of a Prevention System That Supports Developmental Phases Developmental Illustrative Intervention Stage In the Absence of Interventions Opportunities Conception, High risk of postpartum Pregnant women screened routinely pregnancy, depression for risk factors and provided postpartum needed interventions, such as mood management training, home visitation, and nutritional counseling to prevent maternal depression during child’s critical developmental stages Baby at risk for problems of Well-baby visits to screen and attachment, later preschool or intervene for developmental school problems, or later problems, abnormal feeding depression if mother is depressed patterns, interactions with mother or other caretaker Infancy Infant at risk for abnormal Screening is offered for age- development appropriate behaviors and evidence of normal brain development Early behavioral difficulties On-time remedial interventions are increase risk for later bonding offered, such as parent training and problems, negative patterns of referral to a developmental parent-child interactions specialist Preschool years Child does not receive early Caregivers are encouraged to read cognitive stimulation to their children Child does not learn self-efficacy, In-home and out-of-home prosocial skills, or appropriate enrichment experiences such as school behaviors early childhood education are offered for the child to build skills needed for school and social success Families receive needed parenting support to foster nurturing relationships Primary school Child has difficulty establishing Families and schools increase positive relationships with peers, nurturance and decrease punitive caregivers, or teachers experiences Child does not experience early Children learn skills to enhance successes school performance and manage problem behaviors continued

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0 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS TABLE 13-1 Continued Developmental Illustrative Intervention Stage In the Absence of Interventions Opportunities Middle school Early adolescent engages in risky Families and schools provide high- behaviors, such as smoking, level reinforcement for prosocial using alcohol or other drugs, behavior delinquency, or risky sexual behavior Early adolescent experiences few Young people at risk due to academic successes and bonds academic or peer-interaction with deviant peers problems are identified and provided with individual or family intervention options High school Adolescent lacks self-esteem, has Family- and school-focused limited academic success, programs shape attitudes and engages in antisocial behaviors, behaviors around substance abuse, and does not develop positive delinquency, and sexual behaviors health habits and provide self-identity and coping skills Depression, conduct disorder, Adolescents are routinely screened and substance abuse increase for early signs of depression and other MEB disorders, with appropriate interventions provided Young adulthood Young adult flounders in Community programs support transition to independence, decisions about education, work including continued education, and relationships, and model employment, marriage, and parenting skills, including childrearing constructive parent–child communication Young adults struggle with Interventions are available in readiness to have and to parent college, the workplace, and children community settings as needed to reduce obstacles to raising a family, including academic, job-related, and marital difficulties health at the level of member states and communities (Commission of the European Communities, 2005). The green paper launched a process that included consultation with relevant European institutions, governments, health professionals, and stakeholders in the research community and other civic sectors (Commission of the European Communities, 2005). These

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 TOWARD AN IMPROVED APPROACH deliberations on mental health include a strong emphasis on mental health promotion and prevention of mental illness. To work toward developing a comprehensive strategy to address promotion and prevention in mental health, 29 European countries have formed the European Network for Mental Health Promotion and Mental Disorder Prevention. The aim of the network is to serve as an information resource to disseminate evidence-based knowledge and tools and to develop integrated approaches to training, policy, and implementation (Jané-Llopis and Anderson, 2006). Individual countries have linked their prevention programs to the shared policies of the European Union. This includes an emphasis on prenatal programs and a healthy start in life, along with early education programs, which are generally more developed and available than in the United States (Jané-Llopis and Anderson, 2006). In addition, many countries are working to integrate mental health promotion and prevention efforts both with the systems that address physical health and with antipoverty programs, recognizing that poverty is a major factor in the development of MEB disorders (Jané-Llopis and Anderson, 2005). Many European countries experience challenges to translating this interest in promotion and prevention into action; these challenges are similar to those described in this report, including financing, infrastructure, and implementation support (Jané-Llopis and Anderson, 2006). However, there are also notable successes in nationwide implementation and compre- hensive national approaches in Europe and elsewhere that offer promising models from which lessons can potentially be learned. Some countries have undertaken nationwide or widespread implemen- tation of specific evidence-based programs. For example, Parent Manage- ment Training, a program originally developed in the United States, has been adapted in Norway and implemented nationwide through the creation of a national implementation and research center that coordinates training for providers, supervision, consultation, and research in support of imple- mentation with strong partnership at the regional and local levels (Ogden, Forgatch, et al., 2005). Australia has launched a National Mental Health Promotion, Preven- tion, and Early Intervention Action Plan (Commonwealth Department of Health and Aged Care, 2000) as part of a multiyear effort to position mental heath as a new strategic direction. It includes the implementation of multiple policies and programs as part of a national effort. As a component of a national initiative on depression, the Triple P Program (a multilevel parenting program; see Chapter 6) was tested on a population level in multiple Australian communities. It demonstrated significant reductions in the number of children with recognizable and borderline behavioral and emotional problems and the number of parents who reported depression,

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2 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS stress, and coercive parenting, although reductions were modest (Sanders, Ralph, et al., 2008). The Netherlands has a comprehensive national infrastructure for health promotion and prevention that includes public health, mental health, and addiction. This infrastructure includes mechanisms that support research and dissemination of evidence-based programs and involves multiple sec- tors, such as the health system, the justice system, and schools. It is sup- ported by a specialized professional workforce of trained health promoters and prevention workers, about half of whom are primarily or partly focused on mental health (Jané-Llopis and Anderson, 2006). One of the areas of pri- ority is the care of children of mentally ill parents. The Netherlands, as well as Finland, have implemented country-wide systems to support the children of mentally ill parents in their health care systems (see Box 13-1). Scotland launched the National Programme for Improving Mental Health and Well Being in 2001. The key aims include raising awareness and promoting mental health and well-being, eliminating stigma and dis- crimination, preventing suicide, and promoting and supporting recovery from mental illness. The priority areas include, among others, the men- tal health of infants, children, and young people. The national program includes campaigns; research, evaluation, and training initiatives; monitor- ing; partnerships; and implementation support at the national level as well as services and partnerships at the local level (Scottish Executive, 2003). It is guided by a National Advisory Council made up of a range of stakehold- ers from the public and private sectors in a variety of settings, including schools, prisons, and the health system (Jané-Llopis and Anderson, 2006). Information on Scotland’s progress is available at http://www.wellscotland. info/index.html. Systematic attempts to affect the entire population have great value in public health, and integrative models in Europe and other countries may offer efficient approaches to supporting the development of young people, although empirical evidence to date appears to be lacking. Although these models still need more comprehensive study, as the United States moves for- ward with prevention, federal, state, and local governments should look for evidence-based progress in other countries and applicable lessons learned that can be adapted to systems here. CONCLUDING THOUGHTS The gap between what is known and what is being done is far too large. It can be addressed only by continuing to refine the science and by a strong commitment to develop the infrastructure and put in place systems that allow for equitable delivery of preventive interventions on a population- based, large-scale basis. The United States needs to build on the extensive

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 TOWARD AN IMPROVED APPROACH BOX 13-1 Health System–Based Approaches to Prevention in the Netherlands and Finland The Netherlands and Finland have both developed system-wide approaches that initially focused on children of depressed parents and now include prevention work with children of parents with mental illness. The Netherlands The Netherlands began in the 1970s to develop a network of prevention and health promotion teams. These teams were placed in multiple health sectors (e.g., public health, mental health, addiction clinics) and supported by prevention- oriented national institutes and national research centers. The work is part of a national health policy that allots about 5-10 percent of the budgets of community mental health centers for prevention of mental disorders. The experience has been that having preventionists certified to do preventive care has made a difference. It also facilitates the adoption and dissemination of evidence-based programs when they become available and application of continu- ous quality improvement processes. Preventionists have a network in which they collaborate with research institutes. This structure enables a constant interplay between research and practice. It also has provided a vital infrastructure through which to deliver preventive services. Preventive care for children of the mentally ill is an integral part of the mental health and primary health care system. Care of children of parents with mental illness is one of five mental health priority areas. To make care of children of mentally ill parents a regular part of the systems of care (not an isolated activity), adults with mental illness are routinely asked if they have children. If children are present, the family automatically quali- fies for services. Parents and children receive informal home visits and are offered an array of services, including play and talk groups, information support groups, online websites, brochures, videos, school-based education, a buddy system for children and for parents, home-based mother–baby interventions, and parent training. Delivery of services is accompanied by extensive postgraduate training for providers. Many of the practitioners have been educated in Dutch academic and training programs that first focus on prevention, health education, and health promotion. Finland In Finland, under the leadership of Tytti Solantaus, a nationwide program has been developed effectively in a stepwise fashion starting in 2001. The Finnish Child Welfare Act states that if a parent is identified as receiving treatment, the needs of children should be addressed. Before 2001, there had not been a systematic program to do so. The initiative began with the Efficient Family Program, the aim of which is building care of patients’ children into routine practice, with every parent receiving support. This was deliberately conceived as a change from an continued

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4 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 13-1 Continued individual- and treatment-centered program to a family- and prevention-centered one. Mass media campaigns, national and local conferences, and seminars were offered, and the clinics’ leadership and the clinicians were eager to learn. Training began with extensive training of master trainers, who then trained many others. Over time, a decision was made to implement a series of interventions. This included the Family Talk Intervention (see Box 7-3), a 1-2 session intervention using a book for parents, the Let’s Talk About Children discussion, peer groups, and family courses for parents and children. In addition, clinicians or adults (includ- ing parents) responsible for children could request a network meeting attended by all professionals involved in the care of a child to devise a coordinated plan. Health help booklets were also provided. This was combined with an extensive campaign to address postpartum depression. Implementation was accompanied by evaluations, with a randomized trial comparing the Family Talk Intervention with the Let’s Talk About Children discussion under way. Based on research showing that nurses, doctors, psychologists, social workers, and therapists can master the Let’s Talk About Children discussion, the Finnish system now requires that each of these professionals be responsible for initiating child preventive services when working with mentally ill parents. In this approach, prevention services in the Finnish system are not segregated, but rather routinely included in the work of all clinicians. At the end of 2006, there were 650 fully trained professionals and 80 qualified trainers in a country of 5 mil- lion. The work, which began with parental depression, has been extended to drug and alcohol problems, parents with cancer, and other severe physical illnesses. The specific example of children of mentally ill parents takes place against the larger backdrop of Finland’s long tradition of adapting evidence-based preventive interventions in health and mental health nationwide. Their system is set up to accommodate new interventions as they become available. SOURCES: Beardslee, Hosman, et al. (2005); Solantaus and Toikka (2006); Toikka and Solantaus (2006). research now available by addressing gaps in the available research and developing a shared vision and strategy for applying the knowledge at hand. When IOM’s report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research was published in 1994, the majority of available studies were efficacy studies, with a few addressing the effective- ness of interventions. The report called on the field to continue to develop rigorous efficacy and effectiveness evaluations while at the same time mov- ing further toward the final stage in the proposed prevention research cycle to “facilitate large scale implementation and ongoing evaluation of the pre-

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5 TOWARD AN IMPROVED APPROACH ventive intervention program in the community.” It is now clear, however, that achieving community ownership and implementation of science-based preventive interventions is not only an issue of dissemination of information about effective interventions, but also a matter of empirically evaluating strategies achieving effective adoption, implementation, and maintenance of evidence-based preventive interventions. The next major milestone will be the translation of existing knowledge into population-wide reductions in the incidence and prevalence of emotional and behavioral problems. One of the areas of greatest need is to develop strategies and outcome measures to ensure that high-quality evidence-based approaches are successfully adapted for use in a broad array of different cultural, ethnic, and linguistic settings. As research on development and implementation of specific interventions continues, states and communities need to also continuously refine effective interventions and implementation approaches. Similarly, while there has been sustained research over the past 15 years, we recommend attention to areas that have heretofore been neglected, such as effectiveness in real-world situations, cost-effectiveness, integration of genetics and neuroscience with intervention research, and the careful monitoring of rates of disorder and present risk factors to assess whether population-based improvements can be achieved. Without adequate surveil- lance, what the burden of disorder is for the society or where best to direct national resources will not be fully known.

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