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3 Defining the Scope of Prevention T his chapter provides a framework for the report by addressing the conceptual and definitional issues that are fundamental to under- standing the scientific study of prevention. Discussed first are issues in defining the domain of prevention research. While the boundaries between prevention and other concerns, especially treatment, are sometimes difficult to draw, making these distinctions is critical for establishing the scope of the committeeâs work. In this report, prevention is seen as distinct from treatment, but comple- mentary in a common goal of reducing the burden of mental, emotional, and behavioral (MEB) disorders on the healthy development of children and young people. By contrast, health promotion, which some consider as separate from prevention, is viewed by the committee as so closely related that it should be considered a component of prevention. Prevention and health promotion both focus on changing common influences on the devel- opment of children and adolescents in order to aid them in functioning well in meeting lifeâs tasks and challenges and remaining free of cognitive, emotional, and behavioral problems that would impair their functioning. issues in DEFINING prevention Definitional issues have been much discussed since the earliest efforts to bring preventive approaches to the field of mental health and substance abuse. Reducing Risks for Mental Disorders: Frontiers for Preventive Inter- vention Research, the 1994 Institute of Medicine (IOM) report, included an extensive discussion of alternative approaches, including consideration 59
60 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS of the implications of alternative definitions for prevention research and practice. The report argued that âwithout a system for classifying specific interventions, there is no way to obtain accurate information on the type or extent of current activities, . . . and no way to ensure that prevention researchers, practitioners, and policy makers are speaking the same lan- guageâ (Institute of Medicine, 1994, p. 24). Early Frameworks Preventive approaches to MEB disorders have been proposed as a com- plementary approach to the treatment services that have long been societyâs dominant approach to reducing their burden on the population. Treatment services, regardless of their variation in Âcontent, share the common features that people are identified (either by themselves or by others) as currently suffering from a recognizable disÂorder, and they enter treatment with the expectation of receiving some form of relief from the disorder. Prevention is a complementary approach in which services are offered to the general population or to people who are identified as being at risk for a disorder, and they receive services with the expectation that the likelihood of a future disorder will be reduced. Developing definitions that clearly discriminate different types of pre- vention from each other and prevention from treatment is fraught with difficulty. Caplanâs (1964) application of the concepts of primary, second- ary, and tertiary prevention, which are common in a public health context, had an important influence in developing early prevention models. Cowen (1977, 1980) later found that much of what was labeled as primary preven- tion did not meet any rigorous standards for such a definition. He suggested two criteria for primary prevention efforts: (1) that they be intentionally designed to reduce dysfunction or promote health before the onset of dis- order and (2) that they be population focused, targeted either to the whole population or to subgroups with known vulnerabilities. From a developmental perspective, however, many MEB disorders are risk factors for later disorders or disability, so all treatment could poten- tially be labeled as prevention. Gordon (1983) noted that distinctions between prevention and treatment are often based more on historical than on rational or scientific reasons. He reserved the term âpreventionâ for services for those individuals who were identified as not âsuffering from any discomfort or disability from the disease or disorder to be prevented.â Thus the category of tertiary prevention proposed by Caplan (1964), which referred to the prevention of disability for those suffering from disorders, was excluded. Gordon (1983) proposed an alternative threefold classification of pre- vention based on the costs and benefits of delivering the intervention to the
DEFINING THE SCOPE OF PREVENTION 61 targeted population. Universal prevention includes strategies that can be offered to the full population, based on the evidence that it is likely to pro- vide some benefit to all (reduce the probability of disorder), which clearly outweighs the costs and risks of negative consequences. Selective prevention refers to strategies that are targeted to subpopulations identified as being at elevated risk for a disorder. Indicated prevention includes strategies that are targeted to individuals who are identified (or individually screened) as having an increased vulnerability for a disorder based on some individual assessment but who are currently asymptomatic. Selective and indicated prevention strategies might involve more intensive interventions and thus involve greater cost to the participants, since their risk and thus potential benefit from participation would be greater. The 1994 IOM Framework The 1994 IOM report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research emphasized the importance of putting prevention into a broader context, which includes not only treatment but also maintenance interventions when continued care is indicated (Institute of Medicine, 1994). Treatment was distinguished by two features: â(1) case identification and (2) standard treatment for the known disorder, which includes interventions to reduce the likelihood of future co-occurring dis- ordersâ (Institute of Medicine, 1994, p. 23). The features of maintenance were â(1) the patientâs compliance with long-term treatment to reduce relapse and recurrence and (2) the provision of after-care services to the patient, including rehabilitationâ (Institute of Medicine, 1994, p. 24). The term âpreventionâ was reserved for interventions designed to reduce the occurrence of new cases. While noting that neither the Gordon framework (universal, selective, and indicated prevention) nor the public health framework (primary, secondary, and tertiary prevention) was spe- cifically developed for mental health, a modified version of the Gordon approach was adopted. The defining feature for classifying preventive inter- ventions was the population that was targeted. Similar to that of Gordon, the 1994 IOM reportâs rationale for targeting a type of intervention either universally or to a high-risk subgroup was that the potential benefit was substantially higher than the cost and the risk of negative effects. The concepts of universal and selective prevention were essentially the same as in Gordonâs system. The concept of indicated prevention was modified to include interventions targeted to high-risk individuals who do not meet diagnostic criteria for a disorder but who have detectable markers that warn of its onset. The 1994 IOM report acknowledged that some people in the groups targeted for universal, selective, or indicated preventive interventions may
62 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS have mental disorders when the intervention begins. However, if they are selected into the intervention on the basis of being in a high-risk group (selective) or for having early symptoms (indicated), then the intervention is considered preventive. The report also acknowledged that good treat- ment should often include preventive elements to reduce the likelihood of relapse or of disability, but it emphasized that interventions selected on the basis of an existing disorder should be considered treatment rather than prevention. Recent Definitional Debates A significant modification of the classification system developed in the 1994 IOM report was proposed by the National Advisory Mental Health Council (NAMHC) Workgroup on Mental Disorders Prevention Research (1998). This report argued that the IOM system was too narrow because it excluded âall individuals with full-blown disorderâ (National Advisory Mental Health Council Workgroup on Mental Disorders Preven- tion Research, 1998, p. 16). The workgroup recommended expanding the definition of preventive intervention research to include (National Advi- sory Mental Health Council Workgroup on Mental Disorders Prevention Research, 1998, p. 18): trials involving participants who (1) have no current symptoms of Âmental disorder and were never symptomatic; (2) have current sub-clinical symp- toms; (3) have a currently diagnosed disorder and/or were previously symptomaticâfor them the emphasis is on prevention of relapse or recur- rence; or (4) have a currently diagnosed disorder, with the emphasis on prevention of comorbidity or disability. Despite the broadening of the definition of prevention, the report spe- cifically stated that the expanded research agenda âdoes not represent a decreased commitment to preventing mental disorders in people currently without symptoms or those who have never been mentally illâ (National Advisory Mental Health Council Workgroup on Mental Disorders Preven- tion Research, 1998, p. 20). Comments on the report proposed that the broadened definition had sev- eral problems. One concern was that it failed to make distinctions between prevention and treatment, and therefore all treatment could essentially be considered prevention (Greenberg and Weissberg, 2001). Another concern was that the potential relabeling of treatment studies as prevention could dilute resources for prevention research for populations without a diagnosed disorder (Shinn and Toohey, 2001; Heller, 2001; Reiss, 2001). Despite criti- cisms of the broadened definition, others noted that regardless of where the line between prevention and treatment is drawn, benefits could be gained
DEFINING THE SCOPE OF PREVENTION 63 from closer integration of prevention and treatment research, so that meth- odological advances in one area could be applied to the other (Pearson and Koretz, 2001). Similarly, it was suggested that a more unified approach to improving the public health could be developed with interventions that incorporate elements of targeted screening and treatment in a broader pre- ventive approach (Weisz, Sandler, et al., 2005; Brown and Liao, 1999). Recently, a related health care conceptâpersonalized medicineâhas emerged. The adjectives âpredictive,â âpreventive,â and âpreemptiveâ are frequently attached to this concept (Zerhouni, 2006), suggesting that pre- diction based on early information about an individual can lead to the avoidance of disorder, a form of prevention. Personalized medicine was spawned in large part by new and enabling technologies of genomic analysis and involves the use of information about individual-level risks, including genetic or other biomarkers, to identify and intervene in incipient medical disorders. This concept can and has been applied to prevention and pre- emption of MEB disorders. While equating it with indicated and selective prevention, Insel (2008) termed this approach âpreemptive psychiatry,â positing that it offers the greatest potential for the prevention of both physical and mental disorders. The committee views this concept to be a promising dimension of indicated prevention, but as only one component of a broader spectrum of needed approaches. As discussed in Chapter 5, there have been substantial developments in identifying genetic and epigenetic information that may contribute to MEB disorders, as well as increased recognition that environmental exposures, particularly during early development, can interact with genetic characteris- tics to affect gene expression. Similarly, as discussed in Chapter 4, a variety of adverse childhood events, such as early trauma (Anda, Brown, et al., 2007) and other family and community adversities, have been associated with later adverse mental, emotional, and behavioral outcomes. This infor- mation is beginning to be used in predictive models for physical as well as MEB disorders; for example, as discussed later in this report, its application to potential indicated prevention of schizophrenia is very promising. However, this approach is in its early stages and likely to evolve over the next decade or two. Before preemptive psychiatry based primarily on genetic information can be considered ready for widespread implementa- tion, a number of substantial hurdles and risks to implementation must be recognized and addressed, such as the issues of creating a âgenetic under- classâ and differential access to health care and psychoÂpharmaÂcologies (Evans, 2007). More fundamentally, understanding of the causal role of genetic contributors to MEB disorders must be substantially improved. The committeeâs call for collaborations between prevention scientists and clinical developmental neuroscientists is aimed at better understanding
64 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS causality and the moderating genetic or environmental factors associated with mental, emotional, and behavioral outcomes. The public health perspective endorsed by the committee also man- dates that prevention not be limited only to those at imminent risk. Indeed, the mandate of agencies such as the National Institute of Mental Health (NIMH) and the Substance Abuse and Mental Health Services Administra- tion (SAMHSA) calls for a broader approach. For example, the ADAMHA Reorganization Act, which created both, states that the research program at NIMH âshall be designed to further the treatment and prevention of mental illness, the promotion of mental health, and the study of the psychological, social, and legal factors that influence behavior.â Similarly, the Center for Mental Health Services at SAMHSA is directed to establish national priorities for the prevention of mental illness and the promotion of mental health. These mandates suggest a broad-based prevention approach that includes a balance between approaches aimed at those at imminent risk, those at elevated risk, and those who currently appear risk free but for whom specific interventions have been demonstrated to reduce future risk. As Chapter 2 emphasized, the prevalence of MEB disorders among young people suggests that few are entirely risk free. Furthermore, as outlined in this report, a substantial body of research established over the past several decades supports the efficacy or effectiveness of universal and selective interventions, particularly for behavioral disorders. A balance of universal, selective, and indicated prevention research and implementation is needed to address the mental, emotional, and behavioral needs of young people. Consistent with the agenciesâ legislative mandates, targeted attention is also needed to approaches that can promote mental health, regardless of whether a specific disorder is being prevented. THE CURRENT APPROACH The classification system used to define the boundaries of prevention and prevention research is critical for assessing the degree to which preven- tion research and services are being used along with treatment strategies as part of a public health approach to reduce the burden of MEB disorders in the population. And indeed, a variety of approaches have been proposed. The committee recognizes that it may be difficult in some cases to distin- guish different prevention approaches from each other or even to identify clear boundaries between prevention and treatment. We also appreciate the importance of treatment, including its preventive aspects in terms of reduc- ing the likelihood and severity of future problems. Interventions to prevent disability, comorbidity, or relapse are clearly important. However, the committee thinks that these are aspects of quality treat- ment and are distinct from, though complementary to, prevention, concur-
DEFINING THE SCOPE OF PREVENTION 65 ring with the perspective in the 1994 IOM report. We also conclude that the progress made since 1994, as outlined in this report, supports continued focus of prevention resources prior to the onset of disorders. We share the concerns, raised by the 1994 IOM committee and commentators on the NAMHC approach, that an overly inclusive definition of prevention research could dilute resources for interventions designed to prevent the onset of disorder and âoften underlies a neglect of interventions to reduce risksâ (Institute of Medicine, 1994, p. 28). Therefore, in this report, the committee has adopted the definitions of prevention developed in the 1994 IOM report, along with the distinc- tions between prevention and treatment. This report focuses on preventive interventions that target multiple populations whose levels of risk vary, but that are not identified on the basis of having a disorder. As discussed below, however, the committee broadened the conceptualization of mental health to include both the prevention of disorders and the promotion of mental health (see Box 3-1). Reconsidering Mental Health Promotion Mental health promotion is characterized by a focus on well-being rather than prevention of illness and disorder, although it may also decrease the likelihood of disorder. The 1994 IOM report included a general call for assessment of outcomes of mental health promotion activities. It also acknowledged that health is more than just the absence of disease and that the goals and methods of prevention and promotion overlap, but it con- cluded that the evidence of effectiveness of mental health promotion was sparse, particularly in comparison to that for prevention. At this point in time, this committee views the situation differently. There is agreement that mental health promotion can be distinguished from prevention of mental disorders by its focus on healthy outcomes, such as competence and well-being, and that many of these outcomes are intrinsi- cally valued in their own right (e.g., prosocial involvement, spirituality: Catalano, Berglund, et al., 2004; social justice: Sandler, 2007). As stated in the Report of the Surgeon Generalâs Conference on Childrenâs Mental Health (U.S. Public Health Service, 2000), âMental health is a critical component of childrenâs learning and general health. Fostering social and emotional health in children as part of healthy child development must therefore be a national priorityâ (p. 3). There is also increasing evidence that promotion of positive aspects of mental health is an important approach to reducing MEB disorders and related problems as well (National Research Council and Institute of Medicine, 2002; Catalano, Berglund, et al., 2002, 2004; Commission on Positive Youth Development, 2005). These developments have led the committee to conclude that mental health promotion should
66 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 3-1 Definitions of Promotion and Prevention Interventions Mental health promotion interventions: Usually targeted to the general public or a whole population. Interventions aim to enhance individualsâ ability to achieve developmentally appropriate tasks (competence) and a positive sense of self- esteem, mastery, well-being, and social inclusion, and strengthen their ability to cope with adversity. Example: Programs based in schools, community centers, or other Âcommunity- based settings that promote emotional and social competence through activi- ties emphasizing self-control and problem solving. Universal preventive interventions: Targeted to the general public or a whole population that has not been identified on the basis of individual risk. The interven- tion is desirable for everyone in that group. Universal interventions have advan- tages when their costs per individual are low, the intervention is effective and acceptable to the population, and there is a low risk from the intervention. Example: School-based programs offered to all children to teach social and emotional skills or to avoid substance abuse. Programs offered to all parents of sixth graders to provide them with skills to communicate to their children about resisting substance use. Selective preventive interventions: Targeted to individuals or a population sub- group whose risk of developing mental disorders is significantly higher than average. The risk may be imminent or it may be a lifetime risk. Risk groups may be identified on the basis of biological, psychological, or social risk factors that are known to be associated with the onset of a mental, emotional, or behavioral disorder. Selective interventions are most appropriate if their cost is moderate and if the risk of negative effects is minimal or nonexistent. Example: Programs offered to children exposed to risk factors, such as paren- tal divorce, parental mental illness, death of a close relative, or abuse, to reduce risk for adverse mental, emotional, and behavioral outcomes. Indicated preventive interventions: Targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental, emotional, or behavioral disorder, or biological markers indicating preÂ disposition for such a disorder, but who do not meet diagnostic levels at the current time. Indicated interventions might be reasonable even if intervention costs are high and even if the intervention entails some risk. Example: Interventions for children with early problems of aggression or elevated symptoms of depression or anxiety.
DEFINING THE SCOPE OF PREVENTION 67 Trea tme n nt tio ven Pre Ma inte nan n ce tio Promo FIGURE 3-1â Mental health intervention spectrum. SOURCE: Adapted from Institute of Medicine (1994, p. 23). be recognized as an important component of the mental health intervention spectrum, which can serve as a foundation for both prevention and treat- ment of disorders (see Figure 3-1). For purposes of this report, the committee has adopted a definition of mental health promotion that is consistent with concepts described in prior reports in the United States (e.g., Substance Abuse and Mental Health Ser- vices Administration, 2007a) and used in international contexts (e.g., World Health Organization, 2004; JanÃ©-Llopis and Anderson, 2005): Mental health promotion includes efforts to enhance individualsâ ability to achieve developmentally appropriate tasks (developmental competence) and a positive sense of self-esteem, mastery, well-being, and social inclu- sion and to strengthen their ability to cope with adversity. Inclusion of promotion activities is an important conceptual shift for the field. For the past decade, various prevention researchers have argued for a synthesis of prevention and promotion approaches (Greenberg, W Â eissberg, et al., 2003; Catalano, Hawkins, et al., 2002; Cowen, 2000; Weissberg and Greenberg, 1998; Durlak and Wells, 1997). Greenberg and colleagues (2003) have maintained that âproblem prevention programs are most beneficial when they are coordinated with explicit attempts to enhance [young peopleâs] competence, connections to others and contributions to
68 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS their communityâ (p. 427). In the context of youth development, Pittman argued for an increased focus on promotion nearly two decades ago, saying the field needs to move âfrom thinking that youth problems are merely the principal barriers to youth development to thinking that youth development serves as the most effective strategy for the prevention of youth problemsâ (Pittman and Fleming, 1991). In practice there is already considerable overlap between prevention and promotion. Meta-analytic and qualitative reviews of preventive intervention studies demonstrate that many psychosocial prevention programs involve the promotion of child competencies or the healthy functioning of fami- lies, schools, or communities (Durlak and Wells, 1997, 1998; ÂGreenberg, D Â omitrovich, and Bumbarger, 2001). For example, a review of programs that aim to prevent chronic delinquency through early interventions for education and family support found that effective programs have com- mon features of promoting childrenâs cognitive competence and achieve- ment and promoting secure parent-child attachment, positive parenting, and improved educational status for parents (Yoshikawa, 1994). Similarly, reviews of mental health promotion programs for children and young people cite many programs that have been demonstrated both to reduce problems and to increase positive aspects of development (e.g., National Research Council and Institute of Medicine, 2002; Catalano, Berglund, et al., 2002, 2004). Catalano, Berglund, and colleagues (2002, 2004), for example, concluded that several youth development programs that were effective in building positive development in such areas as social, emotional, and cognitive competence as well as self-determination and efficacy were also effective in reducing a range of problem behaviors, such as alcohol and drug use, violence, and aggression. Such findings are compatible with theoretical models in which competence and problem outcomes influence each other over time (see Chapter 4). Furthermore, the committeeâs inclusion of mental health promotion in the purview of the mental health field is also consistent with the recogni- tion that health promotion is an important component of public health that goes beyond prevention of disease (Breslow, 1999). Indeed, health has been defined not simply as the absence of disease, but in a positive way as âa resource for everyday life . . . a positive concept emphasizing social and personal resources as well as physical capabilitiesâ (World Health Organi- zation, 1986). Building on this perspective, a 2004 report of the National Research Council (NRC) and the IOM proposed a new definition specifically for childrenâs health: âthe extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities that allow them to inter- act successfully with their biological, physical, and social environmentsâ (National Research Council and Institute of Medicine, 2004a, p. 33). This
DEFINING THE SCOPE OF PREVENTION 69 approach clearly emphasizes the importance for children of both promotion of mental, emotional, and behavioral health and the prevention of disor- ders. Adopting a more inclusive approach may also be less stigmatizing for young people and their families and increase participation in relevant pro- grams, as the focus shifts from avoiding the possibility of disorder toward helping young people realize their potential. CONCLUSION AND RECOMMENDATION Definitions of prevention are important for identifying the potential contribution of prevention approaches to the overall public health goal of reducing the burden of MEB disorders on children and youth, as well as for distinguishing the complementary contributions of mental health promotion, prevention of disorders, and treatment of disorders. At this time, theory, research, and practice have evolved to support an approach to prevention that aims not only to prevent disorder, but also to promote positive mental, emotional, and behavioral health in young people. Conclusion: The theoretical grounding and empirical testing of approaches to promote mental health have advanced considerably, making it a valuable component of the intervention spectrum warrant- ing additional rigorous research. Prevention and treatment are necessary and complementary compo- nents of a comprehensive approach to the mental, emotional, and behav- ioral health of young people. However, to enable distinctions between the two and to monitor the effectiveness of each, delineations must be made. The committee has decided that the definitions of universal, selective, and indicated prevention, as laid out in the 1994 IOM report, with the addi- tion of mental health promotion, offer the most useful framework for the field. Recommendation 3-1: Research and interventions on the prevention of MEB disorders should focus on interventions that occur before the onset of disorder but should be broadened to include promotion of mental health.