Healthy mental, emotional, and behavioral (MEB) development is a critical foundation for a productive adulthood. Much is known about strategies to support families and communities in strengthening the MEB development of children and youth, by promoting healthy development and also by preventing and mitigating disorder, so that young people reach adulthood ready to thrive and contribute to society. In a 2009 report, Preventing Mental, Emotional, and Behavioral Disorders Among Young People, the National Research Council and Institute of Medicine argued that existing research made the case for support of both prevention and promotion interventions.
In the decade since that report was issued, a growing body of research has significantly strengthened understanding of healthy MEB development and the factors that influence it, as well as how it can be fostered. Yet the United States has not taken full advantage of this growing knowledge base. Ten years later, the nation still is not effectively mitigating risks for poor MEB health outcomes; these risks remain prevalent, and available data show no significant reductions in their prevalence. Indeed, rates of depression, suicide, and self-harm among young people have actually been increasing: In 2015, suicide was the second most common cause of death among young people ages 15 to 24, and between 2005 and 2014, the proportion of adolescents experiencing a major depressive episode increased from 8.7 percent to 11.3 percent.
MEB disorders frequently manifest during childhood or adolescence. They impose significant burdens for individuals and their families, hindering young people’s development into healthy and productive adults. They are also costly to society, accounting for the highest rates of disability in the U.S. population in 2015 and contributing to rates of school dropout, incarceration, and homelessness. The economic burden is great not only in terms of direct spending but also because of lost earnings, reduced productivity, and other indirect costs. The nation’s economic and civic well-being depends on a healthy adult population capable of productive work and stable relationships. Therefore, investment in the healthy MEB development of the next generation promises not only benefits for individuals, families, and communities, but economic benefits as well.
To address the critical gap between achievable goals for both promoting MEB health and reducing the prevalence of MEB disorders, and actual progress
in healthy MEB development, the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services (HHS), together with the Centers for Disease Control and Prevention and the National Institutes of Health, asked the National Academies of Sciences, Engineering, and Medicine to convene an ad hoc committee to assess progress and make recommendations for fostering MEB health in the coming decade. The Committee on Fostering Healthy Mental, Emotional, and Behavioral Development Among Children and Youth—whose members have expertise in behavioral research, child development, child and adolescent psychiatry, education, epidemiology, evaluation research, health care services, implementation science, neuroscience, pediatrics, prevention research, program development, public health, and public policy—was asked to synthesize scientific advances achieved in this area in the past decade and recommend ways in which public and private agencies and organizations can lead efforts to apply this body of knowledge.
APPROACH TO THE CHARGE
Several perspectives affected the committee’s thinking about the topics we would cover and the evidence we would seek.
First, we took a life-course approach, examining influences whose effects begin before conception, continue into young adulthood, and extend across generations. We also recognized the importance of risk and protective factors both at various developmental phases and at the individual, family, community, and societal levels.
Second, our life-course approach dovetailed with a shift in focus since the 2009 report was published from intervening with the individual child to intervening at the societal and community levels so as to influence the environments that affect population health. Thus, we broadened our inquiry beyond prevention strategies that may help the individual child or groups of children, emphasized in the 2009 report, to health promotion and community wellness approaches with greater potential to benefit children across populations. Accordingly, this report is framed to emphasize the importance of integrating promotion efforts to maximize their impact across all children and youth. That is, we took a public health approach focused on programs, policies, practices, and venues that have potential to affect the well-being of children and youth at the population level, including efforts to promote changes in salient values and norms.
Third, we recognized that public health measures are essential to achieving population-level impacts on MEB health outcomes, but cannot by themselves address broader influences on young people’s health and development, such as poverty, systemic racism and discrimination, or health and educational disparities. We therefore took a community approach, one that acknowledges the essential role of the support of county, state, and federal agencies; public education systems; service sectors, such as those for primary health care and behavioral health; businesses; and other local partners in implementing strategies and
effecting changes in communities that can support positive MEB outcomes for children and adolescents.
Building on the 2009 report, this report offers an expanded view of the nature of healthy MEB development and an updated review of strategies for promoting healthy MEB development and preventing MEB disorders. It describes recent progress in understanding what is necessary to implement effective strategies—those for which there is evidence of benefit from multiple trials—at large scales. It also offers our recommendations regarding a national agenda for fostering healthy MEB development among children and youth, and outlines research needed to address remaining gaps in the understanding of MEB development and how it can be strengthened.
INFLUENCES ON MEB HEALTH
In 2009, strong evidence had already established a long list of influences on MEB health in children and youth, including biological, environmental, familial, and societal factors. Since that time, continued work on both biological and environmental influences has demonstrated that MEB development is more complex and interactive than was understood a decade ago.
MEB development is known today to be a product of complex neurobiological processes that interact with characteristics of the physical and social environment, beginning before conception and continuing through and beyond adolescence. Healthy MEB development is shaped by experiences and circumstances that cross generations within families and affect entire communities. Cause-and-effect linkages that shape MEB development have been identified among
- characteristics of the individual’s environment that modulate gene expression and shape neurodevelopment;
- physical, social, and other experiences that affect conception, gestation, and childbirth;
- individual influences, including sleep, nutrition, and physical activity;
- characteristics of the family and surrounding community, including parent characteristics, peer behavior, and school characteristics; and
- characteristics of the broader society in which the individual, family, and community are situated, such as poverty and economic inequality, systemic racism and discrimination, law- and policy-driven factors, and the marketing of unhealthy products.
In effect, children’s social and physical environments literally shape their brains and, consequently, the behaviors and emotions they learn.
PROMOTION AND PREVENTION STRATEGIES
Growing evidence of the interplay among biological, social, and environmental influences on MEB development, beginning before a child is even conceived, has profound implications for the design of interventions to promote healthy MEB development. Researchers have documented evidence for strategies that effectively target risk and protective factors and influence multiple MEB outcomes, and can be implemented universally in health care and education settings. These findings provide the basis for the development of policy and program tools for improving MEB outcomes. Coordinating strategies found to be effective in supporting individuals and families, populations, and multiple generations to address clearly articulated needs is critical to achieving significant benefits relative to the use of ad hoc interventions. Examples include the following:
- Strategies designed to support the mental health of parents and affect the behavior and attitudes of parents and other caregivers and thereby improve outcomes for children and youth, both by enhancing parenting skills and by promoting caregivers’ MEB health. These strategies include screening for caregiver risks and programs to promote healthy parenting and family bonding; screening of women of reproductive age, pregnant women, and mothers for depression (and providing depression treatment); the provision of substance use counseling and treatment for parents; and parent education programs, such as for building awareness of sexual abuse risks.
- Programs delivered in school settings. Examples are programs to teach children in preschool and grades K–12 social and emotional skills, including mindful awareness practices; to promote a positive school environment; to promote access to services for low-resourced populations and communities; and to help young people develop resilience to manage multiple health risks, such as bullying, substance use, and suicidal thoughts.
- Use of primary health care settings to promote healthy MEB development for children and prevent risks for MEB disorders. Strategies include preconception and prenatal care that mitigates risks for unhealthy fetal development, such as exposure to tobacco and alcohol; parenting education and guidance and screening for signs of risks to MEB development; multidisciplinary care, in which nurses and nurse practitioners, social workers, and behaviorally trained practitioners collaborate with physicians to provide care in a single setting; and preventive and therapeutic attention to the behavioral needs of children with serious chronic disorders.
Evidence for the effectiveness of local, state, and federal policies for promoting healthy MEB development in children and youth at a population level
is incomplete. Evidence of benefits for children and families exists for some longstanding programs, such as Medicaid and the Earned Income Tax Credit. Additional research is needed, however, to provide a basis for directing current policies and developing new policies so as to support healthy MEB development in children and youth more effectively.
IMPLEMENTATION AT THE POPULATION LEVEL
Research has also significantly expanded understanding of what is required for effective implementation and scaling of strategies such as those detailed above. These findings align with evidence about the influences on development, highlighting the importance of systematic and integrated approaches and sustained partnerships. Effective implementation of such strategies is facilitated by research focused on identifying the core components of an intervention or policy, as well as the optimal ways to adapt those components for diverse settings. While research has not answered every question about how to implement effective interventions at the population level, it does strongly indicate that a successful process depends on an interactive system with the capacity to support, track the outcomes of, and continuously improve an intervention. Key elements of such a system include
- active engagement of stakeholders (community members, service providers, funders, policy makers, purveyors, and researchers);
- a well-trained community workforce that is provided with ongoing professional development opportunities;
- active leadership within organizations responsible for delivering the intervention;
- the development of strong community coalitions that can muster sustained support for the intervention and provide community-level leadership;
- a system for monitoring the quality and outcomes of implementation efforts, barriers to successful implementation, trends in risk and protective factors and other influences on MEB development, and other relevant data;
- learning through evaluation, including which interventions work for whom, and sharing what is learned among networked programs; and
- multiple methods of communication to publicize and share the intervention objectives with stakeholders and the community at large.
A COMPREHENSIVE NATIONAL AGENDA FOR PROMOTING MEB HEALTH
From the body of work summarized above, it is clear that achieving meaningful improvements in MEB development and health will require a
comprehensive, integrated approach that takes advantage of the full range of research findings about salient influences, effective strategies, and what is required for their successful implementation. Meaningful improvements in MEB health are within reach if such approaches are supported and sustained; if available resources are coordinated around carefully defined shared goals; and if concerted attention is paid to identifying or creating scalable health promotion and prevention interventions, as well as the challenges of implementing these promising interventions at scale.
MEB health will not become a national priority by happenstance. A broad-based effort to improve MEB health—which could be organized under the rubric Decade of Children and Youth and led by HHS—could build awareness of the social and economic gains associated with healthy child development and engage multiple sectors of society in working toward that goal. To support this effort, we offer recommendations in three areas: federal leadership and partnership for a national agenda; implementation and scale-up of effective interventions; and monitoring to support needs assessment, scale-up, program improvement, and outcomes research.
Federal Leadership and Partnership for a National Agenda
Federal agencies are in the best position to articulate why MEB health deserves national attention and the nature of the effort needed. The relevant agencies of the federal government—led by HHS—are well positioned to lead an effort that leverages the potential benefits of a comprehensive, integrated strategy.
Implementation and Scale-Up of Effective Interventions
Progress in successfully implementing interventions for which research has produced evidence of both effectiveness and scalability will be essential for improving MEB development among children and youth at the population level. Ongoing research in implementation science is providing new insights into best practices for implementing promising interventions at scale. This research deserves continuing support.
Monitoring to Support Needs Assessment, Scale-Up, Program Improvement, and Outcomes Research
The collection of information about quality and outcomes is vital to the continuous improvement that fuels the effective implementation of interventions that can benefit large populations. On a broader scale, policy makers and the public need information about the status of the nation’s young people if they are to fully understand risks to MEB development and possibilities for its improvement. A significant amount of relevant data is collected about young people and families in the United States; in particular, the National Survey of
Children’s Health collects state-level data that provide a considerable amount of pertinent information. Nevertheless, the data currently available do not provide adequate information to support improvement in MEB development. Therefore, the United States needs an improved system for the regular collection and coordination of data on indicators of mental, social-emotional, and behavioral development and health at the national, state, and local levels, as well as outcomes data on efforts to promote health, prevent disorders, and address problems in these areas. The data thus collected would be used to identify patterns and trends, areas of need, and vulnerable populations, as well as to support analysis and evaluation of the impact of policies and interventions over time—on both individuals and populations.
As the committee developed our primary conclusions and recommendations, we were struck by their similarity to those of numerous other committees of the National Academies that had addressed related issues in the past decade. Past committees have underscored the importance of coordinating efforts and systems to develop an integrated approach to promoting the health and well-being of children, youth, and families, as well as the critical importance of accurate and comprehensive data collection to inform policy makers and the public about the status of populations, the services provided to them, and the outcomes of those services. The confluence of these messages both supports and amplifies the recommendations of this committee with respect to fostering healthy MEB development. To state the obvious, the risks and challenges associated with economic and other environmental disadvantages in the United States influence not only children’s MEB health but also their physical health, their schooling, and their entry into the world of work.
The Decade of Children and Youth that we propose will require realistic assessments of costs and benefits but is intended to serve as a way of making optimal use of the strong existing foundation of research on the MEB health of children and youth. It is our hope that our recommendations can be considered vital components of an intensive, focused, and sustained effort to improve the currently concerning MEB outcomes experienced by many U.S. children and youth. We do not advocate waiting to pursue goals for improved MEB
development and health until there is national consensus on how to do so and all building blocks are in place. We believe the accumulated weight of the conclusions and recommendations resulting from the body of research documented in this and predecessor reports of the National Academies is now sufficient to motivate rapid and unwavering action.
DIRECTIONS FOR FUTURE RESEARCH
While a strong foundation of research on which to base the launching of the Decade of Children and Youth is in place today, ongoing support for both discovery and application research will be essential to continued progress. Federal support for research relevant to MEB health has tended to focus on diagnosis and treatment of specific disorders at the expense of investigations of the social and behavioral determinants of health and well-being and efforts to promote MEB health population-wide. Research on health promotion and risk prevention and their impact on the incidence and prevalence of MEB disorders, as well as further advances in the science of program implementation, will provide critical opportunities for ongoing progress in fostering MEB health.
The first priority is to continue building on the growing body of work about ways to promote healthy MEB development at the population level. We further recognize the importance of emerging possibilities for reaching populations through school-based interventions and the health care system. The research priorities we identified also reflect the importance of understanding macro-level influences on MEB development and the challenges of population-level implementation of effective programs. High-priority research directions include
- the design and evaluation of interventions to promote the healthy MEB development of children and youth and the well-being of families at the population level;
- assessment of the effectiveness and implementation of school-based interventions;
- the development of successful two-generation interventions in health care through exploration of the effectiveness and sustainability of program models for improving early childhood MEB development;
- research on strategies to improve MEB development through attention to social and economic disparities; and
- the design and evaluation of implementation strategies.
A future in which the MEB health of children and adolescents is a national priority in the United States is possible. If effective programs that promote MEB health and prevent disorders are thoughtfully implemented in communities across the nation, it will be possible to achieve population-level improvements in the rates of those disorders among children and youth and to support the nation’s
youth in reaching adulthood with the social and emotional skills and assets they need to thrive. This report lays out a set of actions—both policy drivers and research priorities—that, if embraced, can help the nation create this future.