1

Introduction

Postsecondary students, from those attending community colleges to professional and graduate students, are reporting rising rates of anxiety, depression, suicidal thoughts, trauma, and substance use (see Box 1-1) (Xiao et al., 2017).¹ Many undergraduate students experience the onset of mental health and substance use problems or an exacerbation of their symptoms during this critical developmental stage (Pedrelli et al., 2015). These increases call for substantial improvements in how the nation’s institutions of higher education engage with students, and for institutions to recognize how their policies, practices, and cultures can affect and support student mental health² and wellbeing more broadly (Posselt, 2018b). Treating mental illness at this stage in an individual’s development is key to lessening the potential for chronic mental conditions. More purposeful engagement by postsecondary institutions can help ameliorate some of the stresses unique to higher education that go beyond, for example, just being a young adult, veteran, or working adult returning to campus.

While mental health and substance use problems have increased significantly over the past decades, there is now heightened awareness about how the crises currently disrupting American life are exacerbating these problems. The COVID-19

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¹ Much of the information on the incidence of mental health and substance use problems among students comes from self-reports and not actual diagnoses. Self-report data can be inaccurate and may not in fact reflect well the true incidence of those issues among students in higher education (Dang et al., 2020). Chapter 6 discusses research needed to address this limitation.

² The committee has chosen to use the term “mental health” to refer collectively to mental health, the absence of or, at least, low levels of substance use, and wellbeing, and the term “mental illness” to refer to diagnosed, serious mental health problems such as depression, bipolar disorder, and anxiety disorder.

pandemic is one. Institutions of higher education have closed campuses, moved instruction online, and mandated physical distancing. This, in turn, has caused substantial disruptions in the lives of the nation’s college students, including loss of income, anxieties about their future educational and job prospects, and disconnection from the social interactions that are a normal part of college and young adult life. Indeed, a Kaiser Family Foundation survey conducted during the spring 2020 outbreak found that 45 percent of adults believed the pandemic affected their mental health, and 19 percent reported that the pandemic had a major effect on it (Kirzinger et al., 2020; Panchal et al., 2020). A weekly survey conducted by Mental Health America found a 19 percent increase in screening for clinical anxiety was already occurring during the first weeks of February and a further 12 percent increase was seen in the first two weeks of March (MHA, 2020a). The National Institute on Drug Abuse has issued an alert that the pandemic could hit some populations with substance use disorders particularly hard (NIDA, 2020d). According to Kaiser Family Foundation researchers, “the pandemic is likely to have both long- and short-term implications for mental health and substance use. Those with mental illness and substance use disorders pre-pandemic, and those newly affected, will likely require mental health and substance use services” (Panchal et al., 2020).

Surveys administered later in the pandemic have suggested these same trends are present at the same or even higher levels in college students (see Box 1-2) (HMN and ACHA, 2020). An April 2020 survey by the American Council of Education found that 41 percent of university presidents ranked student mental health concerns as one of the five most pressing issues facing their institutions (Turk et al., 2020a). In addition, roughly 1,700 respondents to another survey by Active Minds said the pandemic negatively affected their mental health and 20 percent said their mental health had significantly worsened during the pandemic (Active Minds, 2020). More than half of the students surveyed said they would not know where to go if they or someone they knew needed professional mental health services immediately. The rise in the prevalence of mental health problems is not unique to college student populations; the prevalence is rising in adolescent and young adult populations overall.

The second major crisis currently afflicting American life is the economic turmoil that has accompanied the COVID-19 outbreak. Colleges and universities are facing unprecedented financial challenges resulting from the loss of tuition revenues, uncertainty about future enrollment, and the costs of preparing their campuses to allow students, faculty, and staff to return safely, or absent that, preparing to deliver coursework online (Startz, 2020). Faculty, staff, and students alike are experiencing loss of work and wages, which also increase the risks of experiencing mental health and substance use problems. This may be particularly true for students coming from communities of color or lower socioeconomic backgrounds, whom the pandemic has affected disproportionately.

Finally, the nation is facing a third crisis with significant effects on the physical and mental health of students of color and other historically underrepresented groups highlighted by the mass demonstrations and calls for racial justice following the murders of George Floyd, Breonna Taylor, and Ahmaud Arbery. In response to these murders, institutions of higher education, along with many other institutions and structures in our nation, have a growing recognition of the work that must be done to address systemic racism and dismantle inequities. The national energy to address racism and racial disparities raises the imperative to address issues that disproportionately affect students of color and those from other underserved populations so that all students can thrive during and after their years in higher education.

STUDENT WELLBEING IS FOUNDATIONAL FOR SUCCESS

The concept of wellbeing, according to the Centers for Disease Control and Prevention (CDC), refers to “the presence of positive emotions and moods (e.g., contentment or happiness), the absence of negative emotions (e.g., depression or anxiety), satisfaction with life, fulfillment, and positive functioning” (Andrews and Withey, 1976; CDC, 2018; Diener, 2000). Student wellbeing is foundational to academic success.

The CDC and other leading public health organizations argue that wellbeing has mental, emotional, physical, spiritual, social, financial, and other dimensions that, individually and collectively, impact a variety of outcomes of concern to colleges and universities. Student wellbeing is about more than just having happy students: a large body of research has shown that mental health challenges significantly affect academic achievement and graduation rates in postsecondary education (Mojtabai et al., 2015).

Just as wellbeing is a foundational element for students’ success in day-today life, it is equally important for degree completion. However, judging from the figures cited in Box 1-1, far too many postsecondary students are not experiencing a level of wellbeing that will enable them to thrive in an academic setting and reach their full potential.

While dealing with stress is a normal part of life, for some students stress can adversely affect their physical, emotional, and psychological health (Hartley, 2011; Shankar and Park, 2016). Moreover, studies have found that dropout rates for students with a diagnosable mental health problem range from 43 percent (Breslau et al., 2008) to as high as 86 percent (Collins and Mowbray, 2005). This risk is particularly relevant for institutions of higher education given that adolescence and early adulthood is when most mental illnesses are first experienced (American Psychiatric Association, 2018). Mental health issues may appear in children and adolescents. A literature review of related studies found evidence of mental health problems in adolescents, with increases being more prevalent in girls than boys (Haidt and Twenge, 2019). Thus, many undergraduate and

graduate students arrive on campus with an undiagnosed mental illness that becomes salient during their years as students.

Addressing the Mental Health Challenges of Students

In addition to students who may develop mental health challenges during their time in postsecondary education, growing numbers of students arrive on campus with a current mental health or substance use problem or having experienced significant trauma in their lives that intensifies the stress response. Managing that stress response can sap attentional energy—the “bandwidth” necessary for academic success—negatively affect their physical, emotional, and psychological wellbeing (Verschelden, 2017). Stress, such as the isolation students are experiencing during the COVID pandemic, can be a major factor causing relapse and should be factored into plans for dealing with substance use, particularly in the post-pandemic period of full reopening.

Although it is a time of emotional and intellectual growth, pursuing a postsecondary education, whether at a community college, baccalaureate institution, or in a graduate or professional degree program, can be a stressful and challenging experience for many students and negatively affect wellbeing (Larcombe et al., 2016; Liu et al, 2019).

This can be particularly true for students from historically excluded groups such as students who are Black, Indigenous, and people of color, first-generation students; students who graduate from under-resourced high schools, non-native English speakers; students with disabilities; and sexual and gender minorities. While education has been characterized as the great equalizer, institutions of higher education have hardly been immune from the systemic inequalities and racism that have constrained equal opportunity, adding further stressors to students’ academic resilience. Awareness of how students experience stressors within educational environments is critical, whether it is in activating effects of past trauma, revealing undiagnosed mental health issues, or navigating social and institutional mechanisms of privilege and equity. In the general population, studies have indicated that, for some underrepresented minorities, mental illness can be seen as highly stigmatizing and can result in lower treatment-seeking, depending on the context (Gary, 2005; NMHA, 1998; Ward et al., 2014). However, this has not been found to be the case for college students of color. In a study examining enrollment and counseling center service utilization data at 66 universities, Hayes et al. (2011) found no difference in utilization of counseling services between ethnic minority students and European American students. In fact, the authors found that “among students of color, utilization of campus counseling services was predicted by greater psychological distress, less family support, and a history of previous psychological problems.” The authors also found that the ethnic composition of the student body, as well as the ethnic composition of the counseling center staff, predicted the likelihood that students would seek counseling

services. For example, the higher the percentage of African American therapists at a university counseling center, the greater the percentage of African American students who sought services. Some programs that address these issues, including the stigma of mental health for all students as well as underrepresented minority students, are described in Chapter 3.

Results from the Healthy Minds study have shown that across all types of postsecondary institutions and fields of study, students reporting mental health problems were twice as likely as other students to drop out of school before completing their degree (Eisenberg, Golberstein, and Gollust, 2009). Even for those students who do graduate, mental health problems can be associated with breaks in their education (Arria et al., 2013), longer times to graduation, and lower grade point averages. In addition, a Microsoft/Economist Intelligence Unit survey found that 79 percent of postsecondary educators believe that emotional wellbeing is a “very” or “extremely” important factor in student academic success. Seventy percent of those surveyed believed that emotional wellbeing has become more important for student success than when they started their careers (Green, 2019).

Further along in their intellectual and career development, graduate and professional students’ mental health are growing concerns, too. It has been reported that the rates of mental health problems in graduate students is six times that of the general population (Evans et al., 2018). A 2014 report from the University of California, Berkeley, found that 43 to 46 percent of bioscience graduate students reported that they were depressed (Panger, Tryon, and Smith, 2014). A more recent survey of nearly 2,300 doctoral and master’s degree students across all fields found that graduate students were four times more likely to suffer from depression and anxiety than a member of the general public in the same age group (Evans et al., 2018). Greater than 40 percent of graduate students surveyed had moderate to severe anxiety, and nearly 40 percent had moderate to severe depression. Similarly, a 2014 survey of medical students found that 58 percent screened positive for depression and nearly 75 percent reported a high or intermediate level of emotional exhaustion (Dyrbye et al., 2014). In other survey data from 89 institutions, there was considerable variation in the rates of depression and anxiety by field of study and social identities in the graduate and professional student population, suggesting the need for targeted attention and efforts at this level (Posselt, 2016). See Box 1-3 for key definitions related to mental health and substance use.

THE CASE FOR SHARED RESPONSIBILITY

The goal of postsecondary education is to equip students with the knowledge and degree credentials that will enable them to be productive members of society. Hence, it will undoubtedly further an institution’s academic mission to increase student degree completion rates and foster a higher level of student performance and learning via a campus-wide focus on student mental health and wellbeing. One recent study found that 25 percent of students who dropped out of college

with a grade point average less than 3.0 screened positive for at least one mental illness. Another study showed that some 30 percent of college students suffering from depression will drop out of school (Douce and Keeling, 2014). For students from historically underserved groups who may have been underdiagnosed, there may be higher levels of undetected psychiatric problems that increase students’ risk of developing mental health problems while on campus. Attending to the multifactorial dynamics in mental health and wellbeing requires paying attention to the interplay between historical factors in psychiatric diagnosis by race and ethnicity (Chen et al., 2019).

A report from the American Council on Education emphasizes the point, saying, “the connection between mental health issues and student retention, particularly for students from historically underserved groups, has implications for the

economic wellbeing of students and institutions alike. Specifically, the negative effects of mental health and substance use problems on student retention suggest that institutional investments in student mental health are likely to generate both increased tuition revenues for institutions and higher earnings for students who attain a college degree” (Lipson, Lattie, and Eisenberg, 2019). As this report discusses in Chapter 5, investing resources to address student mental health issues and foster student wellbeing can have a sizable return on investment, both for the institution and society at large (Eisenberg, Golberstein, and Hunt, 2009). Additional motivations for postsecondary institutions to promote student wellbeing include transient and repeated relocation away from natural support systems, a rising awareness that higher education’s own culture can compromise wellbeing, and evidence that healthier academic communities are more productive and creative.

Virtually every institution of higher education provides some sort of mental health counseling, typically through a counseling and psychological services center. This institutionalized function, though usually underfunded to provide all of the mental health needs for matriculating students, can lead college and university leaders to assume that simply bolstering their counseling centers could be an acceptable solution to mental health problems that today’s students face. It is the committee’s judgment, however, that counseling centers cannot and should not be expected to solve these problems alone, given that the factors and forces affecting student wellbeing go well beyond the purview and resources that counseling centers can bring to bear. Moreover, the committee believes institutions of higher education need to tackle two significant challenges. First, they must address the challenges arising from the increasing incidence of mental health and substance use issues among students in postsecondary education. In addition, both the institutions and their faculty and staff need to address the issues within higher education institutions themselves that contribute to this increasing incidence. A primary factor in dealing with these issues is the need for institutions to address the inadequate resources currently assigned in most places to counseling centers after decades of mental health interventions designed to identify and refer students to treatment.

Another driver for colleges and universities to improve the mental health and substance use services they offer is accreditation. The Department of Education delegated to accreditation organizations the responsibility to evaluate and certify that colleges and universities are providing quality education and value to the public. In fact, accreditation approval is a key factor in universities and colleges qualifying for federal funding for research and education. These accreditation organizations, such as the Higher Learning Commission, several regional accrediting bodies, and others, have recently strengthened their standards for higher education institutions to track and improve student outcomes in the areas of retention, completion rates, job placement, and graduate school placement, all outcomes that are negatively affected when student mental health issues are not addressed. For example, the new 2020 Higher Learning Commission

accreditation standards state, “the institution pursues educational improvement through goals and strategies that improve retention, persistence and completion rates in its degree programs (Standard 4.C.)” and “the institution implements its plans to systematically improve its operations and student outcomes (Standard 5.C.6).”³

An “all hands” approach, one that emphasizes shared responsibility and a holistic understanding of what it means in practice to support students, is needed if institutions of higher education are to intervene from anything more than a reactive standpoint. Creating this systemic change requires that institutions examine the entire culture and environment of the institution and accept more responsibility for creating learning environments where a changing student population can thrive. Specifically, creating conditions that support mental health and helping students deal with mental health and substance use issues when they arise, including helping them access adequate professional help, requires mobilizing commitment and actions by the entire institution. The committee strongly believes that only through such a multi-pronged strategy (see Chapter 5) can our nation’s institutions of higher education create a supportive environment that will benefit everyone, including faculty and staff who must be active participants in this effort.

In addition to being aware of the ways in which they might exacerbate conditions that undermine student health, faculty have an underacknowledged role in promoting student mental health. This is not to say that faculty should become professional counselors or therapists. They are front-line workers, however, and therefore should have basic training in identifying and speaking with students who may benefit from an intervention for a mental health concern or other stressor, such as food or housing insecurity. Faculty should know about the main offices on campus that provide students with support for basic needs and mental health, as well as those that offer wellbeing programs. Faculty also need training to understand how their own teaching, mentoring, supervision, and lab leadership affect their student’s mental health, and they need opportunities to develop skills and norms that improve their work in these areas (NASEM, 2019b). Again, faculty should not act in the place of trained counselors, but they do need to promote a healthy learning environment, recognize issues, empathize with students, and refer them to professionals who can help.

It is the responsibility of the entire university community (administrators, faculty, and staff)—not solely students and those who treat them—to consider student perspectives and incorporate their suggestions to create an environment of health, safety, inclusiveness, respect, and wellbeing.

Institutional leaders should strive toward wellness of academia as a whole, rather than just focusing on students. The culture of academia can be a hostile

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³ The criteria for accreditation from the Higher Learning Commission can be found at https://www.hlcommission.org/Policies/revised-criteria-for-accreditation.html (accessed August 3, 2020).

environment for students and can create or exacerbate mental health issues. Institutional leadership must consider that asking students to change their own circumstances without institutional help is beyond what can be reasonably expected, particularly for students who come from historically marginalized or excluded populations.

Systemic racism in the United States has a major impact on students’ sense of safety, wellbeing, and mental health, particularly but not only for students of color. Although the impact of systemic racism on student wellbeing and mental health warrants an entirely separate study, the committee emphasizes that it is critical for institutions to examine the extent to which racism affects and threatens students and all other members of the academic community. Listening to the voices of students, staff, and professors who have been the target of racism is the only way to learn how pervasive it is. As a recent report notes, “racial trauma-informed leadership prioritizes listening, demonstrates empathy towards injustices and inequalities experienced by students of color, and creates and adapts resources that respond to their mental health needs” (Steve Fund, 2020).

Institutions should look especially carefully at policies that affect the academic and social environment, including alcohol and other drug policies and policies on sexual harassment and assault, as well as those that govern student organizations such as fraternities and sororities and their off-campus venues.

In summary, to realize long-term, widescale improvements in student wellbeing, institutions should both improve their infrastructure to respond to needs that arise and improve the qualities of environments in which students already work and learn. They need to become more proactive and less reactive in ensuring a climate that promotes wellness for everyone on campus.

BACKGROUND OF THE REPORT

To understand how the culture of a given institution of higher education affects student wellbeing and can trigger student mental health problems or exacerbate existing ones, and to identify approaches that institutions can adopt to foster student wellbeing and help those students who are having difficulties, the National Academies of Sciences, Engineering, and Medicine launched an 18-month consensus study in June 2019. Under the auspices of the Board on Higher Education and Workforce, and in collaboration with the Health and Medicine Division, the National Academies appointed a committee of experts to examine the most current research and consider the ways that institutions of higher education, including community colleges, provide treatment and support for the mental health and wellbeing of undergraduate and graduate students in all fields of study. For the purposes of this report, the term mental health will be used to refer to mental health and emotional and behavioral issues. The term mental illness will be used

specifically in reference to diagnosed serious mental disorders, including depression, schizophrenia, bipolar disorder, or anxiety disorder.

By contrast, wellbeing is a holistic concept referring to both physical and mental health. Mental wellbeing includes a sense of personal safety and security, emotional support and connection, mechanisms to cope with stressors, and access to services when appropriate for short- and long-term care. The committee believes that institutions have a responsibility both to enhance the wellbeing of all students and to provide additional support to a subset of students with more severe emotional distress and mental illness.

The Statement of Task for the Committee on Supporting the Whole Student: Mental Health, Substance Abuse, and Wellbeing in Higher Education includes the following specific tasks:

• Identify and review programs, practices, resources, and policies that institutions of higher education have developed to treat mental health issues and to support wellbeing on campuses.
• Analyze the challenges that institutions face—including financial, cultural, and human resource obstacles and methods to address these challenges.
• Investigate factors related to the funding of and access to mental health services and support for student wellbeing, such as student academic performance and campus climate.
• Examine, to the extent possible, the relationship between student mental health, wellbeing, and rates of alcohol and drug use, and recommend ways in which institutions can address substance use and its effects on campus climate.
• Produce a consensus report with recommendations, as well as derivative products that will be broadly distributed on campuses, at professional society meetings, and in other venues.

Over the course of the 18-month study, the committee held two in-person and two virtual listening sessions with university leaders and administrators, counseling center directors and staff, researchers, and students on four campuses. Participants were asked to comment on the statement of task, share related research, describe mental health services on campus (location of offices, staff organization, and description of roles), and identify issues they saw as priorities in the field. Because a significant portion of the study took place during the height of the COVID-19 outbreak, the committee’s ability to meet and hold discussions in person and conduct information-gathering activities and listening sessions at institutions of various types and sizes and conferences was limited.

The committee also examined data from multiple federal agencies and national professional networks and associations and commissioned the following papers and literature reviews:

Finally, the committee commissioned an analysis by the Counseling Center of the University of Illinois at Urbana-Champaign of previously unpublished data on suicide rates from 2009 to 2018 at 13 campuses that are members of the Big Ten Counseling Centers, modeled on a similar study by Silverman el al., 1997. This analysis can be found in Appendix D.

In conducting its research and making its recommendations, the committee decided to craft its findings and recommendations in ways that apply across the diverse types of academic institutions, and, when possible, point out special circumstances unique to individual types of institutions. The committee also paid greater attention to educational levels and academic fields in which data on student mental health issues were available. The report, therefore, contains some information on graduate students and medical students but focuses primarily on undergraduate students. Even though the committee was asked to investigate mental health issues among Science, Technology, Engineering, Mathematics, and Medicine (STEMM) students where feasible, most of the data relevant to this study are not disaggregated by field. In any case, the issues of mental health, substance use, and wellbeing affect all students in all disciplines, as do the campus services provided to deal with them.

Although mental health issues affect students in all professional fields of study, the committee was explicitly asked by the study sponsors to focus on medical students. It has provided some information on medical students, although given the broad scope of the study, that information is necessarily brief. In its focus on medical students, the committee acknowledges that the mental health issues facing this population frequently also apply to other health professionals

and students pursuing other health degrees. These mental health issues have been exacerbated by the COVID-19 crisis, where all health professionals are facing front line stresses related to the diagnosis, treatment, and care of patients and have been found to be at higher risk of developing psychological distress and other mental health symptoms.

The committee’s approach was to make the majority of its recommendations suitable for all institutions and to point out exceptions to those recommendations where appropriate.

Again, the committee acknowledges that there are limited data available on the mental health of students disaggregated by field. This is unfortunate, as differences by field are likely. For example, authors of a study at California Polytechnic State University found that the university’s engineering students “suffer from certain mental health issues at a much higher rate than the average U.S. college student” (Danowitz and Beddoes, 2018). Further research on fields and subfields may reveal additional information about the specific needs of that population.

DATA SOURCES AND CONSIDERATIONS

Data on mental health and substance use in students can be challenging to interpret for a number of reasons. These data are drawn from different groups of students, including those seeking mental health services in counseling centers, subjects of targeted surveys on specific problems, higher education students in general, and broader segments of an age-equivalent population in and outside academia. Also, multiple methods are used in data collection, and it is important to consider the varying strengths, limitations, and purposes of various measurement approaches.

Much of the information on the incidence of mental health and substance use problems among students is based on self-reports from general population surveys, not actual clinical evaluations. This approach has the advantage of drawing from entire student populations, regardless of contact with health services, but it is also subject to key limitations. Self-report surveys typically rely on brief screens that are correlated with but not equivalent to clinical evaluations, resulting in a certain proportion of false positives and false negatives, depending on the sensitivity and specificity of the screen. In addition, survey self-reports are vulnerable to nonresponse bias, in which systematic differences between survey respondents and nonrespondents may yield results that do not accurately represent the target population (Dang et al., 2020). At the same time, self-reported screens are an economical method for collecting data from large populations, and they remain the predominant approach to estimating the prevalence of mental health conditions in psychiatric epidemiology research.

Data from clinical settings are drawn from students who use mental health services from a counseling center in order to be evaluated or receive treatment. These data have two major strengths: the potential to characterize the full

sub-population (by minimizing or eliminating nonresponse) and the ability to include assessments by clinicians instead of or in addition to self-reported symptoms. The key caveat for clinical data is that they are limited to those who use clinical services and therefore do not represent students who are not accessing those services.

No single data point, or source of data, is capable of conveying the complexity of mental health and substance use problems among students. Multiple approaches and methodologies provide contrasting angles on the same concept and contribute to a richer understanding of the issues. These different approaches need to be taken into account in forming conclusions about the prevalence of mental health and substance use issues in higher education. Chapter 6 describes some of the research needed to help address data limitations.

STRUCTURE OF THE REPORT

Recommendations in this report are directed at the various stakeholders in the U.S. postsecondary education enterprise, including federal and state policy makers and funders, institutions of higher education and their administrators and faculty, as well as the students that the system is intended to educate. The recommendations are intended to help the nation’s institutions of higher education provide guidance that enables all who work and learn within it to create an environment that supports student wellbeing, establishes a culture that destigmatizes mental health issues, and provides those students in need with the appropriate services and resources. At the same time, the committee recognizes that at least some of its recommendations will require funds and institutional capacities that many community colleges, universities, and graduate and medical schools currently lack. For this reason, the committee also includes recommendations for policy makers and funders of higher education to help academic institutions bridge gaps and build capacity for long-term improvement.

As has been the case with other recent reports from the National Academies, such as Graduate STEM Education for the 21st Century, The Science of Effective Mentorship in STEMM, Breaking Through: The Next Generation of Biomedical and Behavioral Sciences Researchers, and The Integration of the Humanities and Arts with Sciences, Engineering, and Medicine in Higher Education: Branches from the Same Tree, improving student wellbeing comes down to an imperative to change institutional culture. Absent culture change, the status quo will remain. It is the committee’s hope that this report will serve as a call to action to faculty members, deans, provosts, presidents, and other university administrators to address the policies and culture of the nation’s institutions of higher education that adversely affect students’ mental health and substance use.

Following this introductory chapter, the remainder of this report lays out the committee’s analysis of the current state of students and institutions regarding mental health, substance use, and wellbeing in Chapters 2. Chapter 3 offers

mental health, substance use, and wellbeing approaches, resources, and programs provided to the general student population, and Chapter 4 covers services provided to students by licensed providers or in a clinical setting. Chapter 5 examines specific challenges and barriers to change and the opportunities to address them with evidence-based interventions. Chapter 5 also contains the report’s major recommendations. Chapter 6 provides a listing of major issues that require additional research if the recommendations in this report are to be fully effective once implemented.