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6 Family, School, and Community Interventions Y oung people develop in the contexts of their family, their school, their community, and the larger culture, which offer multiple opportunities to support healthy development and prevent disÂ order. This chapter first reviews interventions in a variety of settings directed primarily at improving family functioning. These interventions target both expectant parents and families with children of different ages and are discussed in order of developmental stage. The chapter then examines interventions delivered in various school settings that seek to address risks for mental, emotional, and behavioral (MEB) disorders and problems or to foster positive development by focusing on change in developmental processes; this discussion is organized according to school level (e.g., early childhood education) and the developmental processes or behavior(s) targeted. Box 6-1, based on the studies discussed in the chap- ter, illustrates key results of family and school interventions. The section on community interventions describes approaches aimed at Âcommunity- wide change. The final section offers concluding comments based on the information presented in the chapter, but does not include recommen- dations. Chapter 7 reviews preventive interventions that target specific MEB disorders, as well as those aimed at mental health promotion. The discussion in that chapter includes school and community interventions that specifically target substance abuse. Chapter 7 concludes with conclu- sions and recommendations that draw together the evidence from that and the present chapter. 157
158 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-1 Results of Family and School Interventions Parenting Programs (examples: Incredible Years, Positive Parenting Program [Triple P], Strengthening Families Program: for Parents and Youth [SFP 10-14], Adolescent Transitions Program [ATP]) â¢ Reduced aggressive, disruptive, or antisocial behavior â¢ Improved parentâchild interaction â¢ Reduced substance abuse â¢ Improved academic success Home Visiting Programs (examples: Nurse Family Partnership and Healthy Families New York) Home visiting programs that start during pregnancy have demonstrated: â¢ Improved pregnancy outcomes, maternal caregiving, and maternal life course â¢ Prevention of the development of antisocial behavior â¢ Reduced physical abuse, aggression, and harsh parenting Comprehensive Early Education Programs (examples: Perry Preschool P Â rogram, Carolina Abecedarian Project, Child-Parent Centers) â¢ Less child maltreatment â¢ Less use of special education services, less grade retention, higher grade completion â¢ Higher rates of high school graduation and college attendance â¢ Fewer arrests by age 19, higher rates of employment, and higher monthly earnings Family Disruption Interventions New Beginnings Program, an intervention for families undergoing divorce: â¢ Reduced odds of the child reaching diagnostic criteria for any mental disorder â¢ Increased grade point average for adolescents â¢ Reduced number of sexual partners reported by adolescents School-Based Programs Good Behavior Game, a first grade classroom management intervention: â¢ Reduced disruptive behavior and increased academic engaged time â¢ Reduced likelihood that initially aggressive students would receive a diagnosis of conduct disorder by sixth grade â¢ Significantly reduced likelihood that persistently highly aggressive males would receive a diagnosis of antisocial personality disorder as a young adult
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 159 â¢ Prevention of suicidal ideation and suicide attempts â¢ Significantly reduced risk of illicit drug abuse or dependence disorder at ages 19-21 Life Skills Training, a school-based substance use prevention program: â¢ Significantly reduced drug and polydrug (tobacco, alcohol, and marijuana) use three years after the program â¢ Strongest effects when delivered with fidelityâ44 percent fewer drug users; 66 percent fewer polydrug users â¢ Significantly reduced methamphetamine use up to 4.5 years later when com- bined with the Strengthening Families Program Linking Interests of Families and Teachers, a combined familyâschool interven- tion focused on skills and communication: â¢ Reduced levels of aggressive behavior, less involvement with deviant peers and lower arrest rates, less use of alcohol and marijuana â¢ For fifth graders, continued preventive effects three years later Fast Track, a multicomponent intervention in grades K-10: â¢ Reduced self-reported antisocial behavior and significantly reduced incidence of conduct disorder for children at highest initial risk â¢ Significantly reduced incidence of a diagnosis of attention deficit hyperactivity disorder for children at highest initial risk Seattle Social Development Project, a combined elementary grade parentâ teacher training intervention: â¢ Reduced diagnosable mental health disorders by age 24 and heavy alcohol use and violence by age 18 â¢ Effects particularly strong for African Americans Adolescent Transitions Program, a parenting intervention delivered in schools: â¢ Reduced rates of growth in tobacco, alcohol, and marijuana use between ages 11 and 17 and lowered likelihood of being diagnosed with a substance use disorder â¢ Reduced rates of arrest
160 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS PREVENTION AIMED AT FAMILY FUNCTIONING Families are the primary socializing agent of young people. Whether young people develop successfully depends substantially on whether fami- lies provide the physical and psychological conditions children need to acquire developmental competencies. This section begins with a review of the available evidence regarding family-focused prevention at each devel- opmental phase. It then moves to discussion of interventions that can affect family functioning and mental, emotional, and behavioral outcomes regardless of developmental phase. The section closes with a discussion of the effects of family economic well-being on diverse internalizing and externalizing disorders. Pregnancy, Infancy, and Early Development Preconception: Preventing High-Risk Pregnancies Among Teenagers Pregnancies among teenagers, particularly those younger than 16 years of age, are a risk factor for preterm birth, intrauterine growth retardation, and perinatal complications. Adolescent pregnancies are associated with single motherhood, low educational attainment, and low wages, all of which jeopardize childrenâs development (Ayoola, Brewer, and ÂNettleman, 2006). Empirical evidence that unintended pregnancies can be prevented by specific pregnancy prevention programs is limited. Higher-quality studies on average show discouraging outcomes for pregnancy, and most studies are pre-post or quasi-experimental. One meta-analysis of prevention strate- gies aimed at delaying sexual intercourse, improving use of birth control, and reducing the incidence of unintended pregnancy among adolescents found no evidence of beneficial effects for any targeted outcomes (DiCenso, Guyett, et al., 2002). Another found evidence of an effect on contraception and pregnancy but not on sexual activity (Franklin, Grant, et al., 1997). Although effective methods of intervening to prevent teenage pregnan- cies through family-, school-, or clinic-based programs are elusive, further research on the larger normative and cultural context for teenage sexual- ity may lead to approaches that are more effective. The recent decline in teenage pregnancies in the United States (Ventura, Mosher, et al., 2001), for example, suggests that opportunities to address malleable influences do exist. Fetal Development and Infancy Significant risks during fetal development for adverse neurobehavioral outcomes include genetic anomalies, poor maternal nutrition, maternal
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 161 smoking and alcohol and drug use, exposure to neurotoxic substances, maternal depression or stress, low birth weight, and perinatal insults. Inter- ventions that prevent these conditions have the potential to prevent many subsequent problems for the child. For example, recent evidence suggests that reduced exposure of pregnant mothers to lead results in reduced total arrests and arrests for violent crimes of their children at ages 19-24 (Wright, Dietrich, et al., 2008). Universal preventive measures that have been adopted throughout the United States include the removal of lead from paint and gasoline. Another universal preventive measure (U.S. Environmental Protection Agency, 2004) has been warning pregnant women or those anticipating conception about the high methyl mercury content of fish at the top of the marine food chain. Prenatal exposure to this heavy metal has been linked to adverse cognitive and behavioral childhood outcomes (Gao, Yan, et al., 2007; Transande, Schechter, et al., 2006). However, some studies have reported increases in postpartum depression (Hibbeln, 2002) and reductions in childrenâs IQ (Hibbeln, Davis, et al., 2007) as a result of reduced seafood intake, sug- gesting that this area may warrant further study. Preterm Births and Prenatal Care The rate of preterm births in the United States has increased from approximately 8 to 12.5 percent over the past two decades, and attempts to prevent or reduce their frequency (such as by providing access to prena- tal care) have been unsuccessful (Institute of Medicine, 2007c). Reducing preterm births remains a significant opportunity for prevention of MEB disorders in childhood. Half of all mothers and infants in the United States are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal program that serves pregnant and lactating women and children up to age 5 (see http://www.fns.usda.gov/pdWIC_Monthly.htm). Participation in WIC has been associated with improved birth outcomes, such as longer pregnancies, fewer preterm births, decreased prevalence of anemia in childhood, and improved cognitive outcomes (Ryan and Zhou, 2006). Although it is likely that the WIC program contributes to the promotion of mental health of children and youth, the magnitude of this contribution is unknown. Peripartum Depression Changes in sleep, appetite, weight, energy level, and physical comfort in women during pregnancy and postpartum can cause significant emotional strain. Screening for peripartum (prenatal and postpartum) depression is
162 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS routinely recommended for women in primary care (Pignone, Gaynes, et al., 2002; U.S. Preventive Services Task Force, 2002). Specific screening tools exist for peripartum depression, such as the Edinburgh Postnatal Depression Scale (EPDS) (Cox and Holden, 2003), one of several tools rec- ommended by the U.S. Department of Health and Human Servicesâ Agency for Healthcare Research and Quality (Gaynes, Gavin, et al., 2005). Such screening tools as the EPDS have the potential to be modified to identify pregnant women with elevated symptoms of depression who would benefit from indicated interventions. In addition, some self-care tools can be useful as the first step in alleviating symptoms of depression (Bower, Richards, and Lovell, 2001). Such tools, commonly based on cognitive-behavioral therapy (CBT), have emerged in a variety of formats, including booklets, manuals, CD-ROMs, audiotapes, and videotapes (Blenkiron, 2001; Williams and Whitfield, 2001; Gega, Marks, and Mataix-Cols, 2004). CBT has a significant evidence base (e.g., Williams and Whitfield, 2001; Richards, Barkham, et al., 2003; Scogin, Hanson, and Welsh, 2003; Gega, Marks, and Mataix-Cols, 2004), and self-care tools have been successfully incorporated into stepped-care models of depression treatment in primary care settings (for patients with mild to moderate depression), with psychotherapy provided for those who fail to improve (Scogin, Hanson, and Welsh, 2003). Maternal Sensitivity and Infant Attachment Motherâinfant attachment has been the focus of research and is a well- established influence on infantsâ successful development (National Research Council and Institute of Medicine, 2000; see also Chapter 5). A meta- analysis of 51 studies that evaluated interventions to increase maternal sen- sitivity and infant attachment using randomized controlled designs found that on average, the interventions were moderately effective in enhanc- ing sensitivity (Bakersman-ÂKranenburg, van Ijzendoorn, and Juffer, 2003). A total of 23 of the studies used a randomized design to assess impact on attachment and demonstrated a slight effect; interventions focused on directly enhancing sensitivity were significantly more effective than other types of interventions. Home Visiting Home visiting is an intensive intervention that targets successful preg- nancies and infant development. In these highly variable programs, a nurse or paraprofessional begins visiting the mother during the pregnancy or just after birth and continues to do so through the first few years of the childâs life. The majority of programs provide parenting education, information
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 163 about child development, social support to parents, encouragement of positive parentâchild interactions, and social and health services. Some also provide case management services and health and developmental screening for children (Sweet and Appelbaum, 2004). Sweet and Appelbaum (2004) conducted a meta-analysis of experi- mental and quasi-experimental evaluations of 60 home visiting programs. Only a fourth of these programs included home visiting during pregnancy. The authors conclude that on average, families receiving home visiting did better than those in control conditions. Mothers were more likely to pursue education but did not differ in their employment, self-sufficiency, or wel- fare dependence. The programs produced better outcomes in three of five areas of childrenâs cognitive and social-emotional functioning. However, the authors also note that the significant variability across programs makes it difficult to evaluate them as a group. Aos, Lieb, and colleagues (2004) found that average benefits of the 25 programs reviewed exceeded costs. The home visiting program with the best experimental evaluations and strongest results to date is the Nurse-Family Partnership (NFP), which has been evaluated in three randomized controlled trials. NFP is unique in tar- geting only first-time mothers. The theory of change is that women may be more open to support and guidance during their initial pregnancies (Olds, Hill, et al., 2003), which may contribute to the strength of the programâs outcomes. This theory is supported by a randomized controlled trial of another home visiting program, which had a significant impact on first-time mothersâ positive caregiving but not on that of women who were already mothers (Stolk, Mesman, et al., 2007). In the first two trials (in New York and Tennessee), the program improved pregnancy outcomes, maternal care- giving, and the maternal life course and prevented the development of anti- social behavior. The third trial (in Colorado) showed benefits as well. NFP has other distinguishing features that may contribute to the strength of its outcomes. First, the program providers are nurses with both substantial training and credibility regarding pregnancy and infants. The Colorado trial experimentally evaluated the impact of nurses versus paraÂprofessionals and found that nurse visitation produced more benefits compared with the control condition (Olds, Robinson, et al., 2002, 2004). None of the other home visitation interventions reviewed by Gomby (1999) employed nurses as providers. Second, NFP uses well-established techniques to guide changes in specific behaviors, such as smoking, seeking an educa- tion, and getting social support. The focus on smoking in the New York study, in which more than 50 percent of mothers smoked, is especially noteÂworthy given the well-established relationship between smoking dur- ing pregnancy and childrenâs subsequent antisocial behavior and substance use (see Brennan, Grekin, et al., 2002; Wakschlag, Lahey, et al., 1997; Weissman, Warner, et al., 1999).
164 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Since nurses who delivered the NFP trial interventions were also expected to deliver the program in the communities to which it would be disseminated, the trials had elements of effectiveness studies. However, the cost of training and the limited pool of nursing professionals in some com- munities may impede community-wide implementation. A randomized controlled study by DuMont, Mitchell-Herzfeld, et al. (2008) of the Healthy Families New York (HFNY) program suggests that the use of paraÂprofessionals can achieve prevention benefits when targeting women during their first pregnancy. The results of this study are consistent with those for NFP in at least two ways. First, like NFP, HFNY worked with young Âmothers enrolled during their pregnancy (DuMont, Mitchell- Herzfeld, et al., 2008). Â Second, HFNY had a greater impact on psycho- logically vulnerable mothers, results that parallel findings for NFP (Olds, Robinson, et al., 2004). Important differences were also reported. DuMont, Mitchell-Herzfeld, et al. (2008) found greater benefit from delivery of HFNY by paraprofes- sionals than was found in the NFP trial in Colorado (Olds, Robinson, et al., 2002, 2004). This result may be attributable to the larger number of cases in the HFNY study and the limited statistical power of the Colorado NFP trial (Olds, Robinson, et al., 2002). However, further research is needed to determine conclusively whether paraprofessional home visitors can achieve results comparable to those of nurse visitors. Early Childhood and Childhood Aggressive social behavior, which typically begins to emerge during childhood, is a key risk factor for progression of externalizing disorders (see Brook, Cohen, et al., 1992; Kellam, Ling, et al., 1998; Lipsey and Derzon, 1998; ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ Robins and McEvoy, 1990; Tremblay and Schaal, 1996; Woodward and Fergusson, 1999) and also is a predictor of internalizing disorders ( Â Kaltiala-Heino, Rimpela, et al., 2000; Keenan, Shaw, et al., 1998; Kellam, Brown, et al., 2008). There is now extensive evidence on interventions designed to help families develop practices that prevent the development of aggressive and antisocial behavior and its associated problems. These interventions focus on providing training in parenting skills. Seminal research on family interactions by Patterson and colleagues over the past 40 years has shown that harsh and inconsistent parenting practices contribute to aggressive and uncooperative behavior and that positive involvement with children and positive reinforcement of desirable behavior contribute to cooperative and prosocial behavior (e.g., Patterson and Cobb, 1971; Patterson, 1976, 1982). Building on the early parent- ing interventions by Pattersonâs group (e.g., Patterson and Gullion, 1968;
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 165 P Â atterson, 1969, 1974), a number of programs have emerged that target par- ents of children at different developmental stages, including childhood (e.g., Forgatch and DeGarmo, 1999; Webster-Stratton, 1990; Sanders, Markie- Dodds, et al., 2000), early adolescence (e.g., Dishion and Andrews, 1995; Spoth, Goldberg, and Redmond, 1999), and adolescence (Chamberlain, 1990; Henggeler, Clingempeel, et al., 2002). All of these programs teach and encourage parents to (1) use praise and rewards to reinforce desirable behavior; (2) replace criticism and physical punishment with mild and con- sistent negative consequences for undesirable behavior, such as time-out and brief loss of privileges; and (3) increase positive involvement with their chil- dren, such as playing with them, reading to them, and listening to them. The efficacy of interventions focused on parenting skills is well estab- lished (see Lochman and van-den-Steenhoven, 2002; ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ Petrie, Bunn, and Byrne, 2007; Prinz and Jones, 2003; Serketich and Dumas, 1996). ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ In addi- tion, several meta-analyses report positive effects of such interventions across a range of child and parent outcomes for parents of young children (Barlow, Coren, and Stewart-Brown, 2002; Lundahl, Nimer, and Parsons, 2006; Serketich and Dumas, 1996; Kaminski, Valle, et al., 2008). ÂKaminski, Valle, and colleagues (2008) report the greatest effect sizes for programs that include parent training in creating positive parentâchild interactions, increasing effective emotional communication skills, and using time-out and that emphasize parenting consistency. Many parenting programs have been shown in two or more experimental trials to produce positive behavioral outcomes. Two examples of parenting interventions with substantial empirical evidence are highlighted in Boxes 6-2 and 6-3. The Incredible Years (see Box 6-2), a combined parentâschool intervention, has been tested as a selec- tive and indicated intervention for children with aggressive behavior and related problems that have not yet reached clinical levels. It also has been tested in effectiveness trials using indigenous family support personnel and is one of few interventions that has been tested by independent investiga- tors rather than the program developer. The Positive Parenting Program (Triple P) (see Box 6-3) is a multilevel intervention with universal, selec- tive, and indicated components. It recently demonstrated positive results when tested on a population-wide basis in Australia (Sanders, Ralph, et al., 2008). Both programs have also been evaluated as treatment interventions, with positive results for those diagnosed with specific disorders, such as attention deficit hyperactivity disorder (ADHD; e.g., Hoath and Sanders, 2002). Additional parenting interventions are highlighted in the next section. Interventions that combine training in parenting skills with school-based interventions are described later in the chapter.
166 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-2 The Incredible Years Program: A Combined ParentâSchool Intervention The Incredible Years Program (Webster-Stratton, 1990) includes parent, teacher, and social skills training components. The parent-training program shows parents brief videotaped vignettes of p Â arentâchild interactions as examples of positive interactions and communication with their children, the value of praise and reward, and the use of time-out and other mild negative consequences. The program has been extensively evaluated in treating children with conduct disorders and in preventing further aggressive behavior and related problems in children whose behavior is not yet at the clinical level. It has been shown to improve parentsâ use of positive parenting practices; to reduce harsh, critical parenting; and to reduce diverse problem behaviors ( Â Gardner, Burton, and Klimes, 2006; Linares, Montalto, et al., 2006; Patterson, ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ Reid, and Eddy, 2002; Reid, Webster-Stratton, and Beauchaine, 2001). ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ These benefits have been shown for a variety of ethnic groups (Reid, Webster-Stratton, and Beauchaine, 2002; ÂPatterson, Reid, and Eddy, 2002) and when provided by diverse professionals, including teachers, nurses, family support specialists, and social workers (Hutchings, Bywater, et al., 2007; Gardner, Burton, and Klimes, 2006). Barrera, Biglan, and colleagues (2002) evaluated the Incredible Years p Â arenting program as one component of an intervention designed to prevent read- ing failure and the development of aggressive behavior problems among high-risk elementary schoolchildren. Children who received the intervention displayed less negative social behavior than controls. The programâs teacher training component focuses on effective preschool and elementary classroom management, while the social skills component teaches children these skills using dinosaur puppets (Dinosaur School). Gross, Fogg, et al. (2003) evaluated the individual and combined effects of the parent and teacher training for 2- and 3-year-old children in day care centers serving low-income minority families in Chicago. Parents who received the parent training had higher efficacy scores, were less coercive in their discipline, and behaved more posi- tively toward their children than did mothers in the control condition, although the effect on parent coerciveness was not sustained at one-year follow-up. Toddlers who were classed as at high risk for problem behavior at the outset of the study and who were in the parent or teacher training condition improved significantly more than children in the control condition; this improvement was maintained at one-year follow-up. Toddlers in the teacher plus parenting training condition did significantly worse on this measure than those in either the teacher trainingâ or parent Âtrainingâalone condition. Webster-Stratton, Reid, and Stoolmiller (2008) report on an evaluation of the teacher training combined with Dinosaur School. The study involved students in Head Start and first grade classrooms in schools that served children in poverty. Teachers who received the training used more positive classroom management strategies, and their students were rated as more socially competent, better at self-regulation, and having fewer conduct problems.
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 167 BOX 6-3 Triple P: A Multilevel Parenting Intervention The Positive Parenting Program (Triple P) focuses on the general population, not just individual families, and has selected components tailored to at-risk groups (such as young single mothers) or children with behavioral problems. The program includes five levels of parenting guidance based on family needs and preferences. The universal level provides information via mass media about effective parenting and solutions to common childrearing problems. The second level provides brief advice to parents for dealing with specific concerns, such as toileting or bedtime problems; parents are typically reached through contact with primary health care providers, such as pediatricians. The third level provides skills training for parents who are having problems with childrenâs aggressive or uncooperative behavior. The fourth level (standard Triple P) provides up to 12 one-hour sessions on parenting skills for parents whose children have multiple behavioral problems, particularly aggressive behavior. The final level, enhanced Triple P, provides skills and support to deal with parental depression, marital discord, or other family challenges. Sanders, Markie-Dadds, et al. (2000) evaluated three variants of Triple P ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ (enhanced Triple P, standard Triple P, and self-directed training) and a wait-list condition with families of preschoolers who were at risk of developing conduct problems. The two practitioner-assisted interventions were more effective than the self-directed training or the wait-list condition. At one-year follow-up, all three active intervention conditions had similar levels of change in directly observed disruptive behavior. Another randomized controlled evaluation of standard Triple P and enhanced Triple P likewise showed positive effects (Ireland, Â Sanders, and M Â arkie-Dadds, 2003). Sanders, Pidgeon, and colleagues (2004) tested an enhanced version of Triple P that had an additional component to help parents deal with anger problems. This trial also demonstrated significant benefits. A randomized controlled study of the mass media component of Triple P (Sanders, Montgomery, and Brechman-Toussaint, 2000) indicated that children of parents who watched a 12-episode television series had significantly lower levels of disruptive behavior (based on parental reports), and parents expressed higher levels of competence. Prinz, Sanders, and colleagues (2009) recently reported a randomized trial of Triple P in 18 South Carolina counties that was accompanied by a media campaign. This study is noteworthy for being the first to show signifi- cant positive effects of a parenting intervention in an entire population. Early Adolescence Early adolescence is a developmental period during which the preva- lence of substance use, delinquency, and depression begins to rise. There is also evidence of an increase in the rates of teasing and harassment in middle school. Significant physical changes occur with the onset of puberty, along with social changes, including the transition from elementary school
168 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS to middle school or junior high school, increased concern about peer acceptance (Steinberg, 1999), and increased demand for autonomy (Eccles, Midgley, et al., 1993). Major environmental risk factors that are especially important in early adolescence include family poverty and family conflict, as well as inadequate parental monitoring and deviant peer group formation. A key behavioral risk factor is aggressive social behavior, which contributes to social rejec- tion and deviant peer group formation (Patterson, DeBaryshe, and Ramsey, 1989). In addition, young people who use cigarettes and alcohol are more likely to use other drugs (Kandel, Johnson, et al., 1999). More generally, psychological and behavioral problems tend to be interrelated (Biglan, Brennan, et al., 2004). Boxes 6-4 and 6-5 describe two parenting interventions using the par- enting skills techniques discussed above that have been developed and eval- uated in multiple randomized controlled trials. They are adapted to address the unique issues, such as potential substance use and parental monitoring, that arise as young people enter early adolescence. The Strengthening Fami- lies Program (SFP) and adaptations of it (see Box 6-4) is a universal inter- vention that has demonstrated positive results on a range of outcomes. The Adolescent Transitions Program (see Box 6-5) has evolved over a series of trials to an intervention with universal, selective, and indicated components designed for delivery in schools. It has demonstrated long-term effects on substance use and delinquency among both white and minority youth. Lessons from HIV/AIDS Prevention The quality of parentsâ communication about risky sexual behaviors and positive attitudes about responsible sexual behavior can influence their adolescent children (Yang, Stanton, et al., 2007; Dilorio, Pluha, and Belcher, 2003). Without these conversations, adolescents overestimate the level of parental approval of their sexual behaviors, and mothers underes- timate the amount of sexual activity of their adolescents (Jaccard, Dittus, and Gordon, 1998). Such communication appears to depend on warm and supportive parentâchild relationships (Donenberg, Bryant, et al., 2003). Conversely, family conflict and negative affect are associated with behav- ioral problems (Szapocznik and Kurtines, 1993), such as earlier sexual debut (Paikoff, 1995) and generally risky sexual behavior (Biglan, Metzler, et al., 1990). Parental monitoring and an authoritative parenting style are consistently associated with less risky sexual behavior, fewer sexual part- ners, less pregnancy, and increased condom use among youth in the family (see Biglan, Metzler, et al., 1990; Li, Feigelman, and Stanton, 2000; Bell, Bhana, et al., 2008).
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 169 BOX 6-4 Strengthening Families Program and Adaptations: Adolescent Parenting Interventions Both the Strengthening Families Program (SFP) and the Strengthening Fami- lies Program for Parents and Youth 10-14 (SFP 10-14), a video-based adaptation of the original SFP program, help families develop the skills, values, goals, and interaction patterns needed to avoid substance use and other problem behaviors. Spoth and colleagues evaluated SFP 10-14 in two randomized controlled trials involving white, rural families of sixth grade students. Subsequent analyses indi- cate significant effects on reducing substance use (Spoth, Redmond, and Lepper, 1999; Trudeau, Spoth, et al., 2007; Spoth, Clair, et al., 2006) and, to some extent, delinquent behavior (Spoth, Redmond, and Shin, 2000) and internalizing disor- ders (Trudeau, Spoth, 2007). Spoth and colleagues conclude that the program had its impact by changing parentâchild interaction patterns. Two analyses have concluded that the benefits of the program exceed its costs (Aos, Lieb, et al., 2004; Spoth, Guyll, and Day, 2002). Recent analyses of the impact on academic performance found that involve- ment in the program contributed to increased engagement in academic activities in eighth grade, which was in turn predictive of academic success in 12th grade (Spoth, Randall, and Shin, 2008). Spoth, Shin, and colleagues (2006) found that the significant reduction in initiation of both alcohol use and illicit drug use for SFP 10-14 participants did not differ as a function of the risk status of the family. Other longitudinal studies of SFP 10-14 are under way. SFP has been tested in diverse ethnic communities (Kumpfer, Alvarado, et al., 2002). Mixed results have been found (Fox, Gottfredson, et al., 2004). However, a randomized controlled trial of an adaptation of SFP 10-14 for rural African Ameri- can populations, the Strong African American Families Program, demonstrated significant reductions in conduct problems among at-risk groups and improve- ments in parenting, with indications that parenting improvements had a partial mediating effect (Brody, Kogan, et al., 2008). Several interventions target HIV risk reduction. Like other parent- o Â riented interventions, they focus on improving parentâchild communica- tion and supportive parental behaviors and increasing parental monitoring and limit setting. Although no meta-analyses have been conducted for these programs, a growing body of evidence is available for such interventions (Krauss, Goldsamt, and Bula, 1997; Wills, Gibbons, et al., 2003), with some emphasis on minority populations at greater risk (Brody, Dorsey, et al., 2002; Murry, Brody, et al., 2005; Wills, Murry, et al., 2007; Jemmott, Jemmott, et al., 2005). Some interventions have targeted and successfully reduced both early sexual intercourse and substance use (McKay, Bannon, et al., 2007; Prado, Pantin, et al., 2007).
170 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-5 Adolescent Transitions Program: A Multilevel School-Based Parenting Intervention The Adolescent Transitions Program (ATP) is a multilevel, adaptive parent- ing intervention designed to reach parents through middle schools (Dishion and Kavanagh, 2003; Dishion, Kavanagh, et al., 2003). The first randomized controlled trial of the original ATP compared the impact of four alternative approaches. A ver- sion that combined parent and teen elements was shown to improve parentâchild relations and reduce family conflict. A parent focusâonly version reduced school behavior problems and tobacco use and also had a short-term effect on the inci- dence of aggressive and delinquent behaviors (Andrews and Dishion, 1995). A second randomized controlled trial in eight small Oregon communities con- ducted by Irvine, Biglan, and colleagues (1999) evaluated the effectiveness of ATP when delivered by staff who were not mental health professionals. ATP participants showed a number of significant improvements. A more recent version of the program, the Ecological Approach to Family Intervention and Treatment (EcoFIT), consists of parenting information provided through a Family Resource Center, along with parentâchild homework interac- tions that encourage effective family management (Dishion and Stormshak, 2007; Dishion, Kavanagh, et al., 2003). Multiethnic students (58.6 percent minority) and their families in each school were randomly assigned to this intervention or a con- trol condition (Dishion, Kavanagh, et al., 2002). Intervention parents maintained their monitoring practices, which had a preventive effect on substance use. In a longer-term Âfollow-up, ÂConnell, Dishion, and colleagues (2007) found that, rela- tive to randomized matched controls, adolescents in the participating families had lower rates of growth in tobacco, alcohol, and marijuana use; lower rates of arrest; and a lower likelihood of being diagnosed with a substance use disorder. Aos, Lieb, and colleagues (2004) report ATP as a program whose benefits exceed its costs. Two HIV prevention interventions have been tested in multiple Âtrials. Trials of the Chicago HIV Prevention and Adolescent Mental Health p Â roject, a family-based, universal HIV prevention program targeting youth in fourth and fifth grades, showed a number of benefits, such as enhanced family decision making, improved caregiver monitoring, and fewer dis- ruptive difficulties with children (McKay, Chasse, et al., 2004; McBride, Baptiste, et al., 2007; Paikoff, Traube, and McKay, 2007). Familias Unidas, which targets Hispanic immigrant parents and their children, was found to increase parental involvement and improve communication and support, and resulted in fewer adolescent behavior problems (Pantin, Coatsworth, et al., 2003).
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 171 Adolescence Adolescence is a period of more independent decision making and risk taking, when the role of parents remains significant but is matched by the influence of peers. Preventive interventions during this stage of development are typically delivered directly to adolescents through schools, and these are discussed later in this chapter. Some treatment interventions show positive effects for families with adolescents displaying considerable antisocial behavior or substance use. For example, multisystemic therapy (e.g., Henggeler, Clingempeel, et al., 2002) and multidimensional treatment foster care (e.g., Fisher and C Â hamberlain, 2000) have both demonstrated the benefits of comprehensive approaches to improving caregiversâ monitoring and limit setting, as well as positive Â reinforcement and support of prosocial behavior. These ben- efits include reduced escalation of antisocial behavior and substance use. These interventions are based on the same principles of effective parenting as the interventions discussed above and may be adaptable for preven- tion. ÂParental monitoring can also reduce adolescent alcohol use (National Research Council and Institute of Medicine, 2003). Young Adulthood A growing body of research points to the period between age 21, gen- erally viewed as the end of adolescence, and age 25 as a notable develop- mental phase in the transition to adulthood (Furstenberg, Kennedy, et al., 2003). These young adults face unique challenges involving the transition to and from college or full-time jobs (including the military), formation of m Â arriage and families, and assumption of increasingly more responsible roles. At the same time, many of these young adults are living at or return- ing home for long periods of time, increasing the potential role of parents and other family members. Yet little research has been done on family- o Â riented interventions during this developmental phase. Some environments in which young people live introduce new factors that may affect their mental, emotional, and behavioral health, such as the presence of binge drinking and pressures to drink on college campuses. Preliminary evidence suggests that parents can decrease tendencies to drink excessively and alter perceptions about drinking by talking about binge drinking prior to their childâs departure for college (Turrisi, Jaccard, et al., 2001). For young adults who enter the military, exposure to combat and serious trauma can have severe mental, emotional, and behavioral conse- quences. Some of the service branches and other groups are undertaking efforts to deal with such stressors (Saltzman, Babayon, et al., 2008). Many
172 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS of the preventive interventions described in this report are conceptually relevant to members of the armed forces and their families. However, con- sideration of how these interventions could be used in the military context, given differences in service systems and many other aspects of military and civilian life, is beyond the scope of this report. Family Interventions That Span Developmental Periods Such family situations as mental illness, divorce, death, and abuse can affect family functioning and contribute to MEB disorders. Selective inter- ventions to help families deal with these adversities and prevent negative outcomes among children have been developed and tested. Interventions designed for families dealing with parental depression are discussed in Chapter 7. Family Disruption Due to Divorce or Parental Death Compared with adolescents in two-parent homes, those with divorced parents exhibit higher levels of mental, emotional, and behavioral problems and lower levels of success in developmental tasks in childhood and ado- lescence; this increased risk persists into adulthood (Amato and Soboleski, 2001; Amato and Keith, 1991a, 1991b). Parental death is also associated with multiple problems in childhood and adulthood, including more symp- toms of depression and anxiety and higher rates of depression and post- traumatic stress disorder (Cerel, Fristad, et al., 2006; Gersten, Beals, and Kallgren, 1991; Kendler, Gardner, and Prescott, 2002; Melhem, Walker, et al., 2008). Preventive Interventions for Divorcing Families. A number of prevention programs focus on improving outcomes for children who experience paren- tal divorce (Braver, Griffin, and Cookston, 2005; Emery, Sbarra, and Grover, 2005; Grych and Fincham, 1992; Haine, Sandler, et al., 2003; Lee, Picard, and Bain, 1994; Pedro-Carroll, 2005; Sobolewski and King, 2005; Wolchik, Sandler, et al., 2005). Many of these programs work with parents during and after the divorce or target changing the divorce process. At least two programs with positive results work with the mother during and after the divorce to deal with the stressors involved: the Parenting Through Change (PTC; Forgatch and DeGarmo, 1999) program and the New Beginnings Program (Wolchik, Sandler, et al., 2007). A randomized controlled trial of the PTC program demonstrated reductions in coercive parenting, antisocial behavior, and internalizing behavior at 30-month follow-up and reductions in delinquency at 36-month follow-up (DeGarmo, Patterson, and Forgatch, 2004; Martinez and Forgatch, 2001; Patterson, DeGarmo, and Forgatch,
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 173 BOX 6-6 The New Beginnings Program: A Parenting Intervention for Families Dealing with Divorce The New Beginnings Program (NBP) (Wolchik, Sandler, et al., 2007) is designed to strengthen parenting (warmth and discipline), increase fatherâchild contact and nonparental adult support, and reduce divorce Â stressors. The first randomized controlled trial of NBP, which involved an 11-session group program designed to work with divorced residential mothers of children ages 8-15, led to significantly lower levels of child-reported aggression and parent-reported behavior problems and improved parental warmth and discipline. Improvements in maternal warmth partially mediated program effects on childrenâs mental health problems. A second trial involved 240 divorced mothers of children ages 9-12. Compared with a literature-only control group, children whose mothers participated in NBP demonstrated significantly fewer internalizing and externalizing behavior prob- lems; participating mothers had more effective disciplinary techniques and more positive relationships with their children (Wolchik, West, et al., 2000). At six-year follow-up (Wolchik, Sandler, et al., 2002), exposure to the program continued to show positive effects. The effects of fewer mental health problems and improved grade point average were mediated by improvements in parental warmth and discipline attributable to the program (Zhou, Sandler, et al., 2008). 2004). Two trials of the New Beginnings Program demonstrated positive results, with some benefits sustained at six-year follow-up (see Box 6-6). One randomized controlled trial of a program for noncustodial fathers, Dads for Life, has shown positive effects. The program teaches skills to improve fatherâchild relationships and reduce postdivorce interparental conflict. Over a 12-month period, the program reduced childrenâs internal- izing problems, increased parental alliance, and reduced conflict between the parents (Braver, Griffin, and Cookston, 2005). Two studies evaluating the effects of programs targeted at changes in the divorce process have shown positive effects in improving the postdivorce relationship between the par- ents (Emery, Sbarra, and Grover, 2005; Pruett, Insabella, and Â Gustafson, 2005). Finally, programs directed at children through schools have had ben- efits in reducing internalizing and externalizing problems (Pedro-ÂCarroll, Sutton, and Wyman, 1999; Stolberg and Mahler, 1994). Parental Death. A meta-analysis of 13 evaluations of interventions (Currier, Holland, and Neimeyer, 2007) to address the needs of parentally bereaved children failed to find significant effects. The studies had numerous meth- odological weaknesses, however, including small sample sizes and a lack of follow-up assessments.
174 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Two programs that produced mental health outcomes each were tested in a single randomized controlled trial. The Family Bereavement Program was tested in a randomized controlled trial involving 156 families. Com- pared with a literature-only control, results for parents in the program included improved positive parenting, mental health, and coping and a reduction in stressful life events; for children, inhibition of expression of feelings was reduced. No effects were found on measures of childrenâs mental health (Sandler, Ayers, et al., 2003). At 11-month follow-up, the program participants continued to show improvement, and children who had greater internalizing problems when they began the program showed significant decreases. In addition, girls in the intervention condition showed a reduction in externalizing and internalizing problems compared with girls in the control condition (Schmiege, Khoo, et al., 2006). Rotheram-Borus, Lee, and colleagues (2001) report on a randomized controlled trial of an intervention targeting adolescents living with a par- ent in terminal stages of HIV/AIDS. The program helped parents discuss their disease with their children, prepare them for the transition to a new caretaker, and facilitate their coping. Benefits were also found at two years (Rotheram-Borus, Stein, and Lin, 2001) and four years (Rotheram-Borus, Lee, et al., 2003) postinterventionï¿½ . Child Maltreatment Programs that target child maltreatment have the potential to prevent multiple MEB disorders and promote healthy development across several domains of functioning. One meta-analysis reviewed 40 evaluations of selective interventions providing early support (prenatal to age 3) to fami- lies at high risk for child maltreatment (Geeraert, Noortgate, et al., 2004). The authors found a significant decrease in abusive and neglectful acts and a significant risk reduction in such factors as child, parent, and family com- munication and functioning. A meta-analysis by MacLeod and Nelson (2000) reviewed multiple programs designed to promote family wellness and prevent maltreatment of children up to age 12. Examples included home visiting; community-based, multicomponent interventions (providing services such as family support, preschool education or child care, and community development); media interventions; and intensive family preservation services (in-home support programs for families in which maltreatment had already occurred). The study concluded that most interventions designed to promote family well- ness and prevent child maltreatment are successful. Effect sizes were largest for measures of family wellness and smaller for verified or proxy measures of child maltreatment. Differences were also reported between reactive interventions (in response to an incident of maltreatment), which had larger
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 175 effect sizes at postassessment than at follow-up, and proactive interventions, which had larger effect sizes at follow-up than at postÂassessment. These dif- ferences could be attributable to variations in the risks in the populations served or in the ages of the children at the time of the intervention. Supported Foster Care Children and adolescents removed from their parentsâ homes are at high risk for MEB disorders. Recent research at the Oregon Social Learn- ing Center has shown that significantly improved outcomes can be achieved through substantial training, support, and backup of parents, coupled with direct training of young people placed in foster care. Early Intervention Foster Care (EIFC) is built on research that defined a set of critical parenting skills and methods for teaching them to parents and other caregivers (e.g., Forgatch and Martinez, 1999). The program involves a team approach to training and supporting foster parents through daily telephone contacts, weekly support group meetings for foster parents, and a 24-hour hotline. Children also participate in weekly therapeutic play group sessions. In a randomized controlled trial, Fisher, Burraston, and Pears (2005) found that children in the EIFC condition who had experi- enced failed attempts at permanent foster home placement were more likely to have a successful placement than similar children in regular foster care. One reason may be that EIFC children had significantly greater psycho- logical attachment to their foster parents than those in regular foster care. The impact of EIFC was also shown by measures of diurnal variation in cortisol level, which is lowered when young children experience maternal deprivation, including foster care placement (Fisher, Gunnar, et al., 2000). Compared with children in regular foster care, those who received the EIFC intervention had increased diurnal variation in cortisol over the course of the intervention that became similar to the pattern for children who had not been maltreated (Fisher, Stoolmiller, et al., 2007). Price, Chamberlain, and colleagues (2008) randomized 700 foster fami- lies to receive a version of a foster family care program or usual care. The study included a multiethnic and racially diverse sample of children between the ages of 5 and 12. Children who received the foster family care program were significantly more likely to be returned to their biological parents or other relatives and had reduced behavior problems. The intervention reduced the likelihood of a failed placement among those with many prior placements, primarily because of improvements in parenting practices (ÂChamberlain, Price, et al., 2008). A quasi-experimental trial of another enhanced foster care program, the Casey Family Program, showed positive effects (Kessler, Heeringa, et al., 2008). Case workers in the program had higher educations and sala-
176 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS ries, lower caseloads, and access to a wider range of ancillary services (e.g., mental health counseling, tutoring, summer camps). Casey foster parents were provided with more financial resources and had access to more case manager assistance. Finally, youth in the Casey program were offered post- secondary job training or a college scholarshipâa major difference com- pared with the public programs, which did not provide services after age 18. Adult alumni of the Casey Family Program had significantly lower 12- month prevalence of mental disorders than public program alumni, includ- ing major depression, anxiety disorders, and substance use disorders. Effects of Family Poverty and Material Hardship Family poverty and the economic strains associated with such events as job loss frequently undermine family functioning. They are associated with multiple negative behavioral outcomes among children in these families, increase parental depression and spousal and parentâchild conflict, and undermine effective parenting (Knitzer, 2007). Research on interventions related to these factors has produced three notable findings. First, economic risk factors can be modified by government policies, and some experimental studies have demonstrated that such modifications lead to a reduction in emotional and behavioral problems in children (Huston, Duncan, et al., 2005). Second, several studies have demonstrated that interventions directed toward poor parents of young children as well as childrenâs early cogni- tive development are associated with long-term improvement in multiple mental, emotional, and behavioral problems and healthy accomplishment of developmental tasks over several decades of follow-up (Olds, Henderson, et al., 1998; ÂReynolds, Temple, et al., 2001). Third, evaluations of a few programs have found that the mediators that account for these long-term effects include early cognitive development and parental participation in childrenâs education (Reynolds and Ou, 2003), along with strengthening of healthy parenting practices (Epps and Huston, 2007). Despite considerable evidence of the impact of poverty on child and family well-being, experimental research that explores child outcomes due to reducing poverty remains limited. Morris, Duncan, and Clark- Kauffman (2005) analyzed two approaches with the potential to affect family well-being based on seven randomized controlled trials. Four inter- ventions involved income supplementation that provided incentives for mothers to go to work, increasing family income while also protecting government-Âprovided benefits if the jobs were low-paying. Three other interventions sought to motivate mothers to move from welfare to work through mandates and penalties. The former interventions significantly increased income, while the latter did not. Small but significant benefits of the programs occurred among younger children, but small and significant
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 177 detriments were reported for children who were transitioning into early adolescence. Casino Income and Poverty Reduction: Evidence from a Natural Experiment No existing trial has specifically assessed the impact of poverty reduc- tion programs on MEB disorders among young people. However, a study by Costello, Compton, and colleagues (2003) used a natural experimental situation to provide evidence of the benefit of increasing family income in reducing these disorders. Four years into a longitudinal study of a repre- sentative sample of 1,420 children ages 9-13, 350 of whom were American Indian, a casino was opened on the Indian reservation. Income from the casino significantly reduced the percentage of American Indian families in poverty, but did not affect the poverty rate among non-Indian families. Across the eight years of the study, small but significant correlations were seen between family income and the occurrence of psychiatric diagnosis and the number of Âpsychological symptoms in both Indian and non-Indian children. Costello, Compton, and colleagues (2003) also looked at changes in symptoms of externalizing disorders (conduct disorder and oppositional defiant disorder) and internalizing disorders (anxiety and depression) fol- lowing the casinoâs opening. Behavioral symptoms increased significantly among children in families that remained poor as the children moved into adolescence, but declined significantly over the same period for the Indian children who were lifted out of poverty. Similarly, there was a significant decline in the rates of internalizing symptoms for those lifted out of poverty but not in persistently poor Indian children. Although many fewer non- Indian families moved out of poverty, some did. The pattern of changes in total psychological symptoms was the same as in the Indian children. This study has the key features of a multiple-baseline design (Biglan, Ary, et al., 2000); after baseline observations, some of the participants received an âinterventionâ and others did not. Although the increases in income were not assigned randomly to both Indian and non-Indian partici- pants, it is difficult to imagine what other variable might have confounded the change in economic fortunes that occurred for the Indian children. Potential for Future Research on Poverty Reduction Gershoff, Aber, and Raver (2003) identify multiple programs that could improve familiesâ economic well-being: Medicaid, the earned income tax credit, Temporary Assistance to Needy Families, food stamps, federal hous- ing subsidies, the School Lunch Program, minimum wage policy, and WIC.
178 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS The earned income tax credit provides incentives to work because it phases out tax credits gradually as the workerâs income rises. In 2002 it lifted 4.9 million people (2.7 million children) out of poverty (Francis, 2009). The impact of these policies and programs on family economic well- being, family functioning, and mental, emotional, and behavioral outcomes could be evaluated in randomized controlled trials. Such studies would require theory-based hypotheses about the impact of poverty and economic hardship on parental stress, depression, and parenting skills and childrenâs internalizing and externalizing disorders. Developing studies to test these hypotheses empirically should be a public health priority. Prevention Through Schools Schools are second only to families in their potential to affect childrenâs mental health. They can contribute to young peopleâs successful develop- ment by providing nurturance and the opportunity to develop cooperative social relations and social and psychological skills. Thus, it is natural that a considerable number of preventive interventions have been developed for delivery in schools, including preschool settings. Most of these interventions have focused on preventing behavioral problems and externalizing disorders or promoting positive child behav- ior in school, although some positive results have been demonstrated on internalizing disorders, such as depression. Other programs have focused on school structural factors, such as the reward structure for prosocial behavior or schoolâfamily relations. Preventive interventions begun early in life may have comparatively stronger effects because of the malleability of several developmentally central risk factors, such as family relationships, peer interactions, cognitive development, and emotional regulation. Early Childhood Interventions Early Head Start Early Head Start, launched in 1995, is a federally funded extension of the Head Start Program (see below) targeting low-income pregnant women and families with infants and toddlers. Early Head Start programs vary in the services provided but are designed to respond to local needs, with a focus on supporting healthy child development through parenting and family support. A randomized controlled study (Love, Kisker, et al., 2002) involv- ing 3,001 families at 17 sites nationwide indicated that at age 3, children â See http://www.ehsnrc.org/AboutUs/ehs.htm.
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 179 participating in Early Head Start scored significantly higher than those not participating on the Mental Development Index of the Bayley Scales of Infant ÂDevelopment, and fewer of them were in the âat riskâ category on this index. They had significantly larger vocabularies, significantly lower levels of aggressive behavior, higher levels of sustained attention, greater engagement with parents, and less negativity toward parents. Program impact was generally larger among families that enrolled during pregnancy, African American families, and those with a moderate number of risk fac- tors. Families with four or five of the following risk factors did not benefit: no high school education, single parent, teen parent, receiving public assis- tance, and not employed or in school. Two years after program completion, some of the program benefits had dissipated (positive effects on aggressive behavior or negativity during play were not sustained), and additional benefits emerged (including enrollment in formal education programs and positive interactions in the home). Preschool Preschool education has been shown to have positive effects on the language skills, literacy, and general cognitive ability of young children in several evaluations of high-quality programs (Yoshikawa, Schindler, and Caronongen, 2007). Two meta-analyses report overall positive outcomes of preschool programs. In a review of 13 evaluations of state-funded preschool programs for children ages 3-5, Gilliam and Zigler (2001) report improved developmental competence. Although significant impact was limited to kindergarten and first grade, some effects, including increased later school attendance and decreased grade retention, were sustained for several years. Only four of the evaluations assessed behavior problems; one of these showed a significant long-term effect through fourth grade. A second meta-analysis (Nelson, Westhues, and MacLeod, 2003) of universal and indicated (high-risk) preschool prevention programsâmany of which included home visiting, parent training, or preschool education componentsâfound significant program effects on childrenâs cognitive func- tioning (when assessed during preschool years), childrenâs social-emotional functioning (during elementary school), and family functioning (during elementary school). Effects on social-emotional functioning were sustained even after children had finished high school. Programs that provided preschool education had significantly greater effects on childrenâs cognitive development than those that did not. Pre- school children continued to do better in elementary school, but the differ- ences were not significant. Programs with more child and family contact also had significantly greater impact on both cognitive functioning during
180 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS preschool years and family functioning when children were in elementary school. The Centers for Disease Control and Preventionâs (CDCâs) Commu- nity Preventive Services Task Force strongly recommends publicly funded, c Â enter-based, comprehensive early childhood development programs for low-income children ages 3-5. This recommendation is based on evidence of the programsâ effectiveness in preventing developmental delay, as assessed by improvements in grade retention and placement in special education (Anderson, Shinn, et al., 2003). Temple and Reynolds (2007) review the benefits of three comprehensive early education programs: the Perry Preschool Program and the Carolina Abecedarian project, both evaluated in randomized controlled trials, and the Child-Parent Centers (CPC), which employed a comparison condition. All three programs sought to improve educational attainment through a focus on cognitive and language skills and use of small class sizes and well- qualified teachers. The Perry Preschool Program and CPC included a parent intervention, but the Carolina Abecedarian project did not. All three programs conducted follow-up assessments into adulthood, which included at least 87 percent of study participants. Important aca- demic outcomes were found, including less use of special education services, less grade retention (for two of the programs), higher grade completion, a higher rate of high school graduation, and higher rates of college atten- dance. Other program effects included less child maltreatment (in the only program that assessed that outcome), fewer arrests by age 19 (two pro- grams), higher rates of employment (in the two programs that assessed this outcome), and higher monthly earnings (assessed by one program). A study of adults who participated in the Abecedarian project also dem- onstrated reduced levels of depressive symptoms (McLaughlin, Campbell, et al., 2007). Temple and Reynolds (2007) conclude that the benefits of these programs exceeded their costs. A meta-analysis by Aos, Lieb, and colleagues (2004) of these and other early childhood education programs draws a similar conclusion (see also Chapter 9). Although Head Start has been cited by CDC as an example of a feasible program that could diminish harm to young children from disÂadvantaged environments (Anderson, Shinn, et al., 2003), few experimental evaluations of the program have been conducted. Ludwig and Philips (2007) report only one recent randomized controlled trial of the program (Puma, Bell, et al., 2005) and one regression discontinuity design based on data from the 1970s and 1980s (Flay, Biglan, et al., 2005; Ludwig and Miller, 2007). Both studies showed that Head Start has some benefit in improving childrenâs cognitive functioning. The evidence from these studies, considered in the context of other research on the value of early childhood education, points to the likely value of universal access to Head Start for disadvantaged chil-
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 181 dren. At the same time, given the magnitude of the program, the potential value of conclusive evidence of its effect, and the availability of rigorous experimental methods, it is surprising that more experimental evaluations have not been conducted. Several preschool classroom curricula are designed to improve Âteachersâ behavior management of classrooms by reducing child behavior problems and strengthening childrenâs social skills or executive functioning (or both). The Promoting Alternative Thinking Strategies (PATHS) curriculum (see Box 6-7) is an example of a curriculum that has been tested in both pre- school and elementary school settings. Elementary, Middle, and Secondary School Interventions Targeting Child Sexual Abuse As mentioned earlier, child maltreatment, including sexual abuse, is a potent risk factor for emotional and behavioral problems. Davis and Gidycz (2000) report on a meta-analysis of school-based programs aimed at teach- ing children to avoid and report sexual abuse. These programs led to sig- nificant improvement in child knowledge and skills related to sexual abuse prevention. The most effective programs included four or more sessions, active participant involvement (such as role play), and behavioral skills training. However, none of the studies examined effects on the prevalence of abuse, and it is difficult to draw conclusions about potential downstream effects of these programs on the risk for MEB disorders. Targeting Problem Behaviors, Aggression, Violence, and Substance Abuse Many of the target risk factors of preventive interventions are inter- related. In early elementary school, for example, both aggressive and with- drawn behaviors can co-occur, imparting much higher risk than aggressive behavior alone (Kellam, Brown, et al., 1983), and both risk factors are independently linked to concurrent and successive problems in concentra- tion, attention, and poor achievement. Depressive symptoms in this period are also associated with poor achievement (Kellam, Werthamer-Larsson, et al., 1991). Externalizing behavior across different social fields and deviant peer group contact in middle school predict later juvenile arrest and drug use, and much higher levels of risky sexual behavior are seen among those with both internalizing and externalizing problems (Dishion, 2000). The life course of those with multiple problem behaviors is especially negatively affected (Biglan, Brennan, et al., 2004). A variety of school-based interventions have been designed to address risk and protective factors associated with violence, aggression, antisocial
182 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-7 Promoting Alternative Thinking Strategies: A Preschool and Elementary School Curriculum Promoting Alternative Thinking Strategies (PATHS) teaches elementary and preschool children about emotion, self-control, and problem solving. A series of evaluations of randomized controlled trials have reported program benefits for children. The PATHS curriculum (Kusche and Greenberg, 1994) has varied across studies as a function of the age of children, their abilities, and curriculum opportunities. Greenberg, Kusche, and colleagues (1995) report on a randomized controlled trial in which four elementary schools and 14 special education classrooms were randomly assigned to deliver or not deliver the curriculum to students in grades 2 and 3. The school-year curriculum consisted of 60 lessons on emotional and interpersonal understanding, including identifying and appreciating various affec- tive states, and how to control emotions. A Control Signals Poster, modeled after a stop sign with red, yellow, and green lights, taught students emotional control and problem solving in difficult social situations. Students learned to stop and try to calm themselves and think about how to handle the situation, how to implement their plan, and how to evaluate their conduct. Greenberg, Kusche, and colleagues (1995) found that PATHS increased the studentsâ ability to understand and articulate emotions. Special education students had a greater understanding of other peopleâs ability to hide their feelings and the fact that feelings can change. In a randomized wait-list controlled trial of a version of PATHS with deaf children in elementary grades, Greenberg and Kusche (1998) found that PATHS students performed significantly better on a number of cognitive, social, and emo- tional measures. Kam, Greenberg, and Kusche (2004) report on a randomized controlled trial of PATHS in which 18 special education classrooms were assigned to either the intervention or the control. Students received the intervention when they were in first or second grade and completed assessments annually for the following three years. Those who received the program had significantly fewer externalizing and internalizing problems than control students, as well as a greater decrease in depression. PATHS has also been evaluated as a universal intervention in the Fast Track study of the prevention of antisocial behavior. First grade students in schools (378 classrooms) in high-crime neighborhoods in four regions of the United States were randomized to receive or not receive a 57-lesson version of PATHS. Peer sociometric data indicated that PATHS classrooms had lower levels of aggression and hyperactive behavior and a more positive atmosphere, but they did not Âdiffer on any teacher ratings of classroom behavior (Conduct Problems Prevention Research Group, 1999b).
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 183 behavior, and substance use, primarily in middle school group settings (see Chapter 7 for discussion of programs that specifically target substance use and abuse). Many of these interventions involve social skills training using cognitive components that alter perception and attributions or a curriculum designed to change behaviors to improve social relationships or promote nonresponse to provocative situations. Universal interventions are often designed to affect school structure; improve classroom management; or improve studentsâ relationships, self-awareness, or decision-making skills. Selective and indicated interventions tend to focus on skill development. A growing body of research shows that many negative outcomes, such as psychopathology, substance abuse, delinquency, and school fail- ure, have overlapping risk factors and a significant degree of comorbidity (Feinberg, Ridenour, and Greenberg, 2007). Emerging evidence suggests that some programs have positive effects on several of these outcomes (Wilson, Gottfredson, and Najaka, 2001). Numerous meta-analyses of school-based preventive interventions have been conducted, varying in the specific types of programs included, the age range of the interventions, and the target problems. All have reviewed one or more outcomes related to antisocial behavior, violence and aggression, or substance abuse and found significant but small to modest effects on measured outcomes. Although both universal (Centers for Disease Control and Prevention, 2007; Hahn, Fuqua-Whitley, et al., 2007) and selective/indicated interventions show positive effects, effect sizes tend to be greatest for high-risk groups (Wilson and Lipsey, 2006b, 2007; Beelman and Losel, 2006; Mytton, DiGuiseppi, et al., 2006; Wilson, Lipsey, and Derzon, 2003; Wilson, Gottfredson, and Najaka, 2001), and greater for improvements in social competence and antisocial behavior than in substance abuse. Meta-analyses provide support for the positive effects of behavioral interventions (Wilson and Lipsey, 2007; Mytton, DiGuiseppi, et al., 2006; Wilson, Â Gottfredson, and Najaka, 2001) as well as cognitively oriented interventions (Wilson and Lipsey, 2006a, 2006b). There is some indica- tion that programs combining behavioral and cognitive aspects can impact multiple outcomes, specifically social competence and antisocial behavior (Beelmann and Losel, 2006). Wilson, Lipsey, and Derzon (2003) found significant effects of school-based programs on aggressive behavior. Wilson and Lipsey (2007) conclude that program effects have practical as well as statistical significance and forecast that such programs would lead to a 25- 33 percent reduction in the base rate of aggressive problems in an average school. Few programs to date have focused on classroom or behavior man- agement. A meta-analysis that included two such programs found them to have a sizable impact on delinquency (Wilson, Gottfredson, and Najaka, 2001). There is strong evidence for the long-term effects of at least
184 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-8 The Good Behavior Game: An Elementary School Universal Intervention Targeting Classroom Behavior The Good Behavior Game (GBG) is a simple universal program to reinforce appropriate social and classroom behavior in elementary school. The theory of the program is that reducing early aggressive behavior will change the developmental trajectory leading to multiple problems in later life. Classrooms are divided into teams, and each team can win rewards if the entire team is âon taskâ (e.g., fewer than a specified number of rule violations during the game period) or otherwise acting in accordance with previously stated teacher expectations. Rewards include extra free time, stars on charts, and special team privileges. The GBG has been tested in multiple trials, including some that measured long- term results. A review by Embry (2002) emphasizes the strength of the evidence and concludes that the GBG (1) dramatically reduced disruptive behavior and increased academic engaged time, and (2) had effects that have been replicated across elementary school grades, among preschoolers, and in other countries. Kellam and colleagues (Kellam, Werthamer-Larsson, et al., 1991; Kellam, Rebok, et al., 1994) evaluated the long-term impact of the GBG in a randomized controlled trial with 19 Baltimore schools that compared the program with a test of mastery learning among first graders (Block, 1984) and usual practice. The GBG reduced aggressive and disruptive behavior during first grade (Dolan, Kellam, et al., 1993; Kellam, Rebok, et al., 1994; Rebok, Hawkins, et al., 1996; Kellam, Ling, et al., 1998). By middle school, recipients of the GBG had lower rates of smoking (Kellam and Anthony, 1998), and those who had initially been aggressive had experienced less growth in aggressive behavior (MuthÃ©n, Brown, et al., 2002). Petras, Kellam, et al. (2008) used latent class analysis to assess the long-term (at ages 19-21) impact of the GBG on aggressive male behavior. The program significantly reduced the likelihood that persistently highly aggressive boys would receive a diagnosis of antisocial personality disorder as a young adult. It also pre- vented suicidal ideation and suicide attempts (Wilcox, Kellam, et al., 2008). Other analyses of outcomes at ages 19-21 showed that the GBG significantly reduced the risk of alcohol or illicit drug abuse or dependence (Kellam, Brown, et al., 2008) and use of mental health and drug services (Poduska, Kellam, et al., 2008); there were no effects on anxiety and depression. Aos, Lieb, and colleagues (2004) report that the benefits of the GBG exceed its costs. one classroom intervention, the Good Behavior Game (see Box 6-8), on aggression and mental health and substance abuseârelated outcomes, particularly among boys. Preventive interventions can also have a positive effect on academic outcomes, although few studies have measured this outcome (Hoagwood, Olin, et al., 2007; Durlak, Weissberg, et al., 2007). A meta-analysis of programs that include academic achievement as an outcome concluded that
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 185 the effects of social and emotional learning programs were equivalent to a 10 percent point gain in test performance (Durlak, Weissberg, et al., 2007). Students participating in the program also demonstrated improvements in school attendance, school discipline, and grades. Hoagwood, Olin, et al. (2007) found similar results in a review of school-based interventions that targeted psychological problems, with 15 of 24 studies showing benefits for both psychological functioning and academic performance. However, the academic effects were modest and often short-lived. Reviews of violence prevention initiatives support their efficacy in reducing violence and aggressive behavior (Centers for Disease Control and Prevention, 2007; Hahn, Fuqua-Whitley, et al., 2007). Based on a system- atic review and meta-analysis of 53 universal prevention interventions, the CDC Task Force on Community Preventive Services recommends the use of universal school-based programs for preventing violence and improving behaviors in school. The effects of the reviewed programs were generally greater among preschool and elementary school-age children (Centers for Disease Control and Prevention, 2007). A recent report by the surgeon general disputes the myth that nothing works with respect to treating or preventing violent behavior (U.S. Public Health Service, 2001c). The report identifies 7 model and 21 promising programs, primarily school-based, for preventing either violence or risk factors for violence. The Center for the Study and Prevention of Violence applies a rigorous set of criteria (experimental design, effect size, replication capacity, sustain- ability) to identify programs effective in reducing adolescent violent crime, aggression, violence, or substance abuse. The center has identified 11 model programs and 17 promising programs, several of which are highlighted in this and the next chapter. Most have demonstrated positive effects on multiple problem outcomes. Combined School and Family Interventions in Elementary School A number of interventions that combine multiple types of programs (e.g., parenting and schools) or multiple levels (e.g., universal and selective) are beginning to emerge, primarily in elementary schools. The Incredible Years Program (see Box 6-2) combines parent and school interventions and has been tested in both preschool and elementary settings. In some cases, integrated efforts have included a family or school-based â See http://www.surgeongeneral.gov/library/youthviolence/toc.html. â See http://www.colorado.edu/cspv/blueprints. Other recommended school-based programs not highlighted in these chapters listed on this site include the Olweus Bullying Prevention Program and the I Can Problem Solve Program.
186 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-9 Fast Track: A Comprehensive, Long-Term, Multilevel Intervention for Students at High Risk of Antisocial Behavior Fast Track is a multisite randomized controlled trial of a comprehensive and extended intervention to prevent antisocial behavior (Conduct Problems Research Group, 1999a, 1999b). Schools in Washington State, North Carolina, Tennessee, and rural Pennsylvania were chosen to participate because they had high rates of crime and poverty in their neighborhoods. Schools at each site were matched on demographics and randomized to the intervention or a usual care control con- dition. Three successive cohorts of kindergarten students in these schools were screened for teacher-rated conduct problems. Those who scored among the top 40 percent were further screened using parent ratings of behavior problems. The standardized sum of these scores was used to select a sample of 446 control children and 445 intervention children who scored highest in conduct problems. The intervention continued through 10th grade. In the younger grades, it included parenting behavior management training, social and cognitive skills training for students, tutoring in reading, and home visiting. In 5th and 6th grades there was increased focus on monitoring and limit setting. In 7th and 8th grades, students received lessons on identity and vocational goal setting. During 7th and 10th grades, assessments occurred three times a year, and further individualized interventions were implemented with each youth, based on his or her behavior and needs. The children and their families were also exposed to the PATHS program (see Box 6-7). The Conduct Problems Research Group (2007) reports the effects of the intervention as of 9th grade, primary among which was less antisocial behavior for the intervention students. There were no main effects on the incidence of diagnoses of conduct disorder, oppositional defiant disorder, or attention Âdeficit hyperactivity disorder (ADHD). Among the highest-risk youth who received the intervention, only 5 percent received a conduct disorder diagnosis, while 21 percent received it in the usual care condition (the rate was 4 percent in the normaÂtive sample). The rate of ADHD diagnosis was also significantly lower in the high-risk intervention sample than in the high-risk usual care sample. It is likely that providing this intervention only to high-risk children would have a favorable benefit-to-cost ratio. intervention that has already demonstrated positive effects separately. For example, the Linking Interests of Families and Teachers (LIFT) project incorporated behavioral parent skills training and a variant of the Good Behavior Game, with preventive effects sustained at three-year Â follow-up (Eddy, Reid, and Fetrow, 2000). The Fast Track project (see Box 6-9) incor- porates PATHS as one part of a comprehensive, long-term intervention with universal, selective, and indicated components. The long-term effects of Fast Track were most significant for the highest-risk participants.
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 187 The Seattle Social Development project, a universal quasi-experimental intervention in the elementary grades, was designed to reduce risk and build protective strengths in schools, families, and children themselves. Long-term follow-up revealed multiple positive effects on mental health, functioning in school and work, and sexual health 15 years after the intervention ended (Hawkins, Kosterman, et al., 2005, 2008). COMMUNITY INTERVENTIONS Preventive interventions in communities generally have two features. First, they target the prevention of an outcome in an entire population in the community, such as tobacco use among adolescents. Community inter- vention research provides a target of manageable size for testing whether such population-wide effects can be achieved. Second, these interventions target multiple influences on the behavior of interest, often through multiple channels. Community interventions are attractive because they can encom- pass all major influences on a behavior. Most experimental evaluations of community interventions involve the prevention of adolescent use of tobacco, alcohol, or other drugs. These studies are discussed in the substance use section of Chapter 7, which focuses on disorder-specific prevention approaches. Flay, Graumlich, and colleagues (2004) evaluated one comprehensive community intervention and a social skills curriculum for preventing mul- tiple problems among early adolescents. A total of 12 poor predominantly African American schools in Chicago were randomly assigned to receive the social skills curriculum, a school/community intervention, or a health education control condition. The social skills curriculum was especially designed for African American young people. The school/community inter- vention added several elements to the social skills curriculum: (1) in-service training of school staff; (2) a local task force to develop policies, conduct schoolwide fairs, seek funds for the school, and conduct field trips for par- ents and children; and (3) parent training workshops. Both the social skills curriculum and the school/community intervention significantly reduced the rate of increase in violent behavior, provoking behavior, school delin- quency, drug use, and recent sexual intercourse and condom use among boys compared with the control condition. The school/community inter- ventions were significantly more effective than the social skills intervention on a combined behavioral measure. Girls, who generally had lower rates of problem behavior, were not affected by the program. A subsequent analysis showed that the effects were due to changes in the boys who were at high- est risk (Segawa, Ngwe, et al., 2005). Much remains to be learned about how to mount effective interven- tions in entire communities. The predominance of the single-problem focus
188 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS on substance use in existing evaluations of community interventions high- lights a significant gap in the field given that community-wide interven- tions, including those that incorporate components targeting families and schools, have the potential to address a wider set of common risk factors comprehensively. Communities That Care, a system to help communities identify and prioritize risk factors and implement tested interventions that address those factors, is being tested in a randomized trial with positive initial results (see Box 11-1). The media and the Internet are emerging as means to reach local com- munities beyond schools and families, as well as the broader community, more widely. Their extensive use by todayâs young people makes develop- ment and testing of evidence-based promotion and prevention interventions using these venues particularly attractive. For example, Triple P (see Box 6-3) has had some positive results in communicating information about parenting via the media. If effective media-based interventions were avail- able, they could be especially valuable in cases in which the local health care system has not allocated resources for preventive services, or the com- munity, school, workplace, or family unit has chosen not to participate in preventive programs. There are early indications that interventions pro- vided on CD-ROM can be effective at reducing risk of alcohol use, drug use, and violence (Schinke, Schwinn, et al., 2004; Schinke, Di Noia, and Galssman, 2004). A series of creative studies has demonstrated the wide reach and effec- tiveness of entertainment media approaches. One of the pioneers in this area is Miguel Sabido (Singhal, Cody, et al., 2003). Using social-cognitive techniques developed by Albert Bandura (2006), Sabido has documented significant impact of these approaches in Mexico on such practices as the utilization of national literacy resources and family planning. The latter was measured by documenting the use of contraceptives, which showed annual increases of 4 percent and 7 percent, respectively, in the two years preceding the airing of a television serial novel (telenovela) addressing family planning and 23 percent in the year the program was aired. Studies of the impact of electronic media (such as television, Âcomputer- assisted interventions, and websites) on other health-related behaviors have also found positive effects in such areas as cognitive-behavioral mood management skills (MuÃ±oz, Glish, et al., 1982), Â mental health interven- tions (Marks, Cavanagh, and Gega, 2007; Barak, Hen, et al., 2008), and smoking cessation (MuÃ±oz, Lenert, et al., 2006). The National Institute for Health and Clinical Excellence in the United Kingdom has approved two computerized cognitive-behavioral therapy interventions for depression and panic/phobia disorders (Christensen and Griffiths, 2002). The Psychosocial â See http://www.nice.org.uk/TA97.
FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS 189 Intervention Development Workgroup of the National Institute of Mental Health has recommended the development and testing of Â Internet-based preventive interventions focused on many disorders and many languages (Hollon, MuÃ±oz, et al., 2002). The potential of media-based interventions for the prevention of MEB disorders warrants additional research. CONCLUDING COMMENTS Meta-analyses and numerous randomized controlled trials have dem- onstrated strong empirical support for interventions aimed at improving parentÂing and family functioning. Interventions focused on reducing aggres- sive behavior, avoiding substance use, reducing HIV risk, securing perma- nent foster care placement, and dealing with difficult family situations such as divorce have all produced beneficial effects. The interventions emphasize improving communication; promoting positive parenting techniques, such as parentsâ supportive behaviors toward their children; reducing the use of harsh discipline practices; and increasing parental monitoring and limit setting. Many interventions have demonstrated effects on multiple problem behaviors, shown positive effects in both prevention and treatment con- texts, and produced lasting effects. Generic efforts to improve parenting skills in families with children and early adolescents could have benefits in preventing a range of problem behaviors, particularly externalizing behaviors. This possibility deserves more exploration through assessment of the impact of family interventions on the entire range of child and adolescent problems. Substantial development of empirically validated school-based pro- grams that can reduce risk for MEB disorders in young people has also occurred. Many of these interventions focus on promoting positive child behavior or preventing behavior problems, with some positive results tar- geting MEB disorders more specifically. Interventions are often designed to address risk and protective factors associated with violence, aggression, and substance use. Many tend to focus on skill development to improve studentsâ relationships, self-awareness, and decision-making skills. Some programs have also focused on school structural factors, teacher classroom management, or schoolâfamily relations. Universal, selected, and indicated interventions have been developed for both school and family settings, with some programs including multilevel interventions. Studies have shown differential results in terms of effective- ness with different risk groups. There are some indications that interven- tions provided on a CD-ROM can be effective at reducing risk of alcohol use, particularly with parent involvement (Schinke, Schwinn, et al., 2004). Some studies have demonstrated better results for higher-risk groups, while
190 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS others have shown positive effects overall but reduced benefits for groups with multiple risk factors. Several interventions highlighted in this chapter have been tested in two or more randomized controlled trials and in evaluations by researchers other than the developers of the interventions. Evidence has been found for long-term results with different populations. Many other promising inter- ventions have not yet been subjected to this level of testing. Given the convergence of evidence related to the positive effects of interventions aimed at improving family functioning and family support, the committee concludes that this area warrants both concerted dissemi- nation and continued research. Some factors, such as poverty, that have notable effects on multiple disorders but have not been subjected to much empirical research merit rigorous evaluation. Similarly, the evidence of positive effects from school-based interven- tions points to the considerable potentialâwith the support of continued evaluation and implementation research in collaboration with educatorsâof prevention practices in schools aimed at increasing the resilience of children and reducing the risk for MEB disorders. Also promising are interventions at the level of communities, including local community interventions, as well as mass media and Internet interventions, and approaches targeting policies, which warrant continued and rigorous research.