What if there were an approach that could improve the well-being of millions of children and adolescents and save the nation as much as $247 billion a year? That approach already exists, according to a recent report from the National Research Council and Institute of Medicine: prevention.
Drawing heavily on psychological research, the report argues that preventing mental, emotional and behavioral disorders among children and adolescents should be a national priority. The report recommends the use of evidence-based interventions, increased funding for prevention research and the creation of a White House office to coordinate efforts.
"The report represents a wonderful opportunity for this country to take what we have demonstrated is possible and make it a real living service that improves the lives of children and, consequently, the lives of the next generation," says Irwin Sandler, PhD, who directs the Prevention Research Center at Arizona State University in Tempe and helped write the report.
The report, Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (National Academies Press, 2009), was sponsored by the U.S. Substance Abuse and Mental Health Services Administration, National Institute on Drug Abuse, National Institute of Mental Health and National Institute on Alcohol Abuse and Alcoholism. It is available online.
Advances in prevention research
The report is a follow-up to the 1994 Institute of Medicine report, Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research.
That first report identified several prevention techniques that appeared promising and a few that had demonstrated effectiveness. Since then, says Sandler, progress has been extraordinary. "The effects of prevention are now quite well documented," he says.
Some of the prevention efforts described in the new report target young people who are already at risk of developing disorders. A cognitive-behavioral prevention intervention developed by psychologist Gregory N. Clarke, PhD, for instance, teaches adolescents at risk for depression how to manage stress.
The 15-session group intervention has had dramatic effects when it comes to preventing depression in several well-respected studies, says committee member Ricardo F. Muñoz, PhD, a psychology professor in the University of California, San Francisco department of psychiatry and chief psychologist at San Francisco General Hospital. In one randomized trial, just 14.5 percent of the adolescents assigned to the intervention developed full-blown depression in contrast to almost 25 percent of those in the control group. In a second randomized trial, which focused the target population to kids whose parents were depressed, only 9 percent of the group receiving the intervention became depressed versus 29 percent of those receiving usual care.
"Depression is the No. 1 cause of disability worldwide," says Muñoz, who helped craft both the 1994 and the new report. "Imagine if we could prevent a quarter to half of cases."
Other interventions have a much broader scope. The Good Behavior Game developed by Shep Kellam, MD, for example, uses extra free time and other rewards to reinforce desirable behavior in teams of elementary school students. Despite the intervention's simplicity, studies have shown it has long-term effects, including lowering the risks of suicidality and alcohol and drug abuse. It also reduces the chances that aggressive boys will receive diagnoses of antisocial personality disorder once they grow up.
Some interventions don't even focus on children directly. A Positive Parenting Program developed by psychologist Ron Prinz, PhD, for instance, uses media campaigns and other strategies to teach parents how to handle child-raising problems. The intervention has a lasting impact on children, says the report, reducing their aggressiveness and lack of cooperation.
To committee member Teresa LaFromboise, PhD, an associate professor of counseling psychology at Stanford, one of the exciting things about the report is the attention it pays to diverse populations. Recognizing that a one-size-fits-all approach doesn't work when it comes to prevention, she says, the report's authors made a special point of including cases where interventions were used in specific ethnic-minority populations. In addition, she says, the methodology chapter offers helpful guidelines for evaluating programs in diverse settings.
From research to practice
The report doesn't just summarize the research, however. It's also a call to action, says committee member Anthony Biglan, PhD, senior research scientist at the Oregon Research Institute in Eugene.
Psychologists and the public alike could use the report to ensure they're doing what works, says Biglan. "If there's a school board member, county commissioner or city council member interested in prevention, they can start saying, 'Hey, are we using evidence-based practices?'" he says.
But the committee hopes the report will have a much broader impact as well.
One key recommendation is to increase the resources available for prevention research.
"The National Institutes of Health got $10 billion of stimulus funds, but we do not see very much of that money being spent on prevention research," says Biglan. "We think that's a significant problem."
Biglan himself has launched a Web site to give scientists a place to push for increased investment in prevention research.
That doesn't mean the committee is against funding for treatment research, emphasizes Muñoz. Instead, they want to reduce the need for treatment by stopping problems before they begin.
"If we found accident after accident in a certain section of the road, we would certainly send emergency personnel to take care of the victims of each accident as it happens," he points out. "But if we did this time after time and did nothing else, we would not be doing our job. Ideally, we should also send personnel to see why there are so many accidents in this part of the road and do something to reduce the number of new accidents."
Research on how to move interventions from the lab to the field is especially important, adds Sandler. "These randomized efficacy trials are run by well-funded research shops where the investigator is implementing the program with a high level of effort and consequently a high level of skill and fidelity," he explains. "That's different from what happens in the real world."
To coordinate all these efforts, the report calls for the White House to create a "prevention czar." Currently, says Biglan, each NIH institute focuses on its own set of problems. NIDA studies drug abuse; NIMH depression. What's needed, the report says, is for all the research and practice agencies to coordinate their efforts. "It's the same conditions that produce all these different problems," says Biglan.
The committee's psychologist members are already working to make these and other recommendations a reality. They're meeting with APA's government relations staff to explore ways of reaching legislators, especially as the debate about health-care reform heats up.
"We certainly hope to move this from research to practice," says Sandler.
Rebecca A. Clay is a writer in Washington, D.C.