Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilties

"Mental health and substance use disorders among children, youth, and young adults are major threats to the health and well-being of younger populations which often carryover into adulthood. The costs of treatment for mental health and addictive disorders, which crease an enormous burden on the affected individuals, their families, and society, have stimulated increasing interest in prevention practices that can impede the onset or reduce the severity of the disorders.

Prevention practices have emerged in a variety of settings, including programs for selected at-risk populations (such as children and youth in the child welfare system), school-based interventions, interventions in primary care settings, and community services designed to address a broad array of mental health needs and populations.

Preventing Mental, Emotional, and Behavioral Disorders Among Young People updates a 1994 Institute of Medicine book, Reducing Risks for Mental Disorders, focusing special attention on the research base and program experience with younger populations that have emerged since that time.

Researchers, such as those involved in prevention science, mental health, education, substance abuse, juvenile justice, health, child and youth development, as well as policy makers involved in state and local mental health, substance abuse, welfare, education, and justice will depend on this updated information on the status of research and suggested directions for the field of mental health and prevention of disorders."

The National Research Council and the Institute of Medicine have reviewed the literature on preventing mental, emotional, and behavioral (MEB) disorders.  While most MEB disorders are diagnosed during childhood or adolescence, the national approach in general has been to target MEB disorders only after they have surfaced in an individual, already after it has become an interference with one’s health.  Hence, the authors have made several recommendations in regards to prevention of mental disorders, based upon their research findings:

Putting Knowledge into Practice

• Funding and Implementation
  • Congress should establish a set-aside for prevention services and innovation in the Community Mental Health Services Block Grant, similar to the set-aside in the Substance Abuse Prevention and Treatment Block Grant.
  • The U.S. Departments of Health and Human Services, Education, and Justice should braid funding of research and practice so that the impact of programs and practices that are being funded by service agencies (e.g., the Substance Abuse and Mental Health Services Administration, the Office of State and Drug Free Schools, the Office of Juvenile Justice and Delinquency Prevention) are experimentally evaluated through research funded by other agencies.  This should include developing appropriate infrastructure through which evidence-based programs and practices can be delivered and evaluated.
  • The U.S. Departments of Health and Human Services, Education, and Justice should fund states, counties, and local communities to implement and continuously improve evidence-based approaches to mental health promotion and prevention of MEB disorders in systems of care that work with young people and their families.
  • The U.S. Departments of Health and Human Services, Education, and Justice should develop strategies to identify communities with significant community-level risk factors and target resources to those communities.
  • Researchers and community organizations should form partnerships to develop evaluations of (1) adaption of existing interventions in response to community-specific cultural characteristics; (2) preventive interventions designed based on research principles in response to community concerns; and (3) preventive interventions that have been developed in the community, have demonstrated feasibility of implementation and acceptability in that community, but lack experimental evidence of effectiveness.
  • Federal and state agencies should prioritize the use of evidence-based programs and promote the rigorous evaluation of prevention and promotion programs in a variety of settings in order to increase our knowledge base of what works, for whom, and under what conditions.  The definition of evidence-based should be determined by applying established scientific criteria.
• Data Collection and Monitoring
  • The U.S. Department of Health and Human Services should be required to provide (1) annual data on the prevalence of MEB disorders in young people, using an accepted current taxonomy, and (2) data that can provide indicators and trends for key risk and protective factors that serve as significant predictors for MEB disorders.
  • The Substance Abuse and Mental Health Services Administration should expand its current data collection to include measures of service use across multiple agencies that work with vulnerable populations of young people.
• Workforce Development
  • The U.S. Departments of Health and Human Services, Education, and Justice should convene a national conference on training in prevention and promotion to (1) set guidelines for model prevention research and practice training programs and (2) contribute to the development of training standards for certifying trainees and accrediting prevention training programs in specific disciplines, such as health (including mental health), education, and social work.
  • Once guidelines have been developed, the U.S. Departments of Health and Human Services, Education, and Justice should set aside funds for competitive prevention training grants to support development and dissemination of model interdisciplinary training programs.  Training should span creation, implementation, and evaluation of effective preventive interventions.
  • Training programs for relevant health (including mental health), education, and social work professionals should include prevention of MEB disorders and promotion of mental, emotional, and behavioral health.  National certifying and accrediting bodies for training should set relevant standards using available evidence on identifying and managing risks and preclinical systems of MEB disorders.

Continuing a Course of Rigorous Research

• Overall
  • Research funders should find preventive intervention research on (1) risk and protective factors for specific disorders, (2) risk and protective factors that lead to multiple MEB problems and disorders, and (3) promotion of individual, family, school, and community competencies.
  • Research funders should invest in studies that (1) aim to replicate findings from earlier trials, (2) evaluate long-term outcomes of preventive interventions across multiple outcomes, and (3) test the extent to which each prevention program is effective in different race, ethnic, gender, and developmental groups.
  • The National Institute of Health and other federal agencies should increase funding for research on prevention and promotion strategies that reduce multiple MEB disorders and that strengthen accomplishment of age appropriate developmental tasks.  High priority should be given to increasing collaboration and joint funding across institutes and across federal agencies that are responsible for separate but developmentally related outcomes.
  • Research funders should strongly support research to improve the effectiveness of current interventions and the creation of new, more effective interventions with the goal of wide-scale implementation of these interventions.
• Screening Linked to Interventions
  • Research funders should support a rigorous research agenda to develop and test community-based partnership models involving systems such as education (including preschool), primary care, and behavioral health to screen for risks and early MEB problems and assess implementation of evidence-based preventive responses to identified needs.
• Implementation
  • The National Institutes of Health should be charged with developing methodologies to address major gaps in current prevention science approaches, including the study of dissemination and implementation of successful interventions.
  • Research funders should fund research and evaluation on dissemination strategies designed to identify effective approaches to implementation of evidence-based programs, (2) the effectiveness of programs when implemented by communities, and (3) identification of core elements of evidence-based programs, dissemination, and institutionalization strategies that might facilitate implementation.
  • Research funders should fund research on state- or community-wide implementation of interventions to promote mental, emotional, or behavioral health or prevent MEB disorders that meet established scientific standards of effectiveness.
• Adaptation
  • Research funders should prioritize the evaluation and implementation of programs to promote mental, emotional, or behavioral health or prevent MEB in ethic minority communities.  Priorities should include the testing and adoption of culturally appropriate adaptations of evidence-based interventions developed in one culture to determine if they work in other cultures and encouragement of adoption when they do.
• Neuroscience Linkages
  • Research funders, let buy the National Institutes of Health, should dedicate more resources to formulating and testing hypotheses of the effects of genetic, environmental, and epigenetic influences on brain development across the developmental span of childhood, with a special focus on pregnancy, infancy, and early childhood.
  • The National Institutes of Health should lead efforts to study the feasibility and ethics of using individually identified genetic and other neurobiological risk factors to target preventive interventions for MEB disorders.
  • Research funders, led by the National Institutes of Health, should dedicate resources to support collaborations between prevention scientists and basic and clinical developmental neuroscientists.  Such collaborations should include both basic science approaches and evaluations of the effects of prevention trials on neurobiological outcomes, as well as the use of animal models to identify and test causal mechanisms and theories of pathogenesis.
  • Research funders, led by the National Institutes of Health, should fund research consortia to develop multidisciplinary teams with the expertise in developmental neuroscience, developmental psychopathology, and preventive intervention science to foster transitional research studies leading to more effective prevention efforts.
• Economic Analyses
  • The National Institutes of Health, in consultation with government agencies, private-sector organizations, and key researchers, should develop outcome measures and guidelines for economic analyses of prevention and promotion interventions.  The guidelines should be widely disseminated to relevant government agencies and foundations and to prevention researchers.
  • Funders of intervention research should incorporate guidelines and measures related to economic analysis in their program announcements and provide supplemental funding for projects that include economic analyses.  Once available, supplemental funding should also be provided for projects with protocols that incorporate recommended outcome measures.
• Competencies
  • Research funders, led by the National Institutes of Health, should increase funding for research on the etiology and development of competencies and healthy functioning of young people, as well as how healthy functioning protects against the development of MEB disorders.
  • The National Institutes of Health should develop measures of developmental competencies and positive mental health across developmental stages that are comparable to measures used for MEB disorders.  These measures should be developed in consultation with leading research and other key stakeholders and routinely used in mental health promotion intervention studies.
• Technology
  • Research funders should support research on the effectiveness of mass media and Internet interventions, including approaches to reducing stigma.
• Other Research Gaps
  • Research funders should address significant research gaps, such as preventive interventions with adolescents and young adults, in certain high-risk groups (e.g., children with chronic diseases, children in foster care), and in primary care settings; interventions to address poverty; approaches that combine interventions at multiple developmental phases; and approaches that integrate individual, family, school, and community-level interventions.

Recommendations for Researchers

• Researcher and interventions on the prevention of MEB disorders should focus on interventions that occur before the onset of disorder but should be broad-ended to include promotion of mental, emotional, and behavioral health.
• Prevention researchers should broaden the range of outcomes included in evaluations of prevention programs and policies to include relevant MEB disorders and related problems, as well as common positive outcomes, such as accomplishment of age-appropriate developmental tasks (e.g., school, social, and work outcomes).  They should also adequately explore and report on potential iatrogenic effects.
• Researchers should include analysis if the costs and cost-effectiveness (and whenever possible cost-benefit) of interventions in evaluations of effectiveness studies (in contrast with efficacy trials).
• Researchers and community organizations should form partnerships to develop evaluations of (1) adaptation of existing interventions in response to community-specific cultural characteristics; (2) preventive interventions designed based on research principles in response to community concerns; and (3) preventive interventions that have been developed in the community, have demonstrated feasibility of implementation and acceptability in that community, but lack experimental evidence of effectiveness.      

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