Child and Adolescent Mental and Behavioral Health Resolution

Promoting children's mental and behavioral health¹ underlies healthy development and health equity across the lifespan. Advances across broad areas of behavioral, social and neuroscience inform practice, programs, and policy in child and adolescent mental and behavioral health.²

The Importance of Development  

Most common mental disorders, including those with the greatest morbidity, have an onset in childhood or adolescence (Kessler & Wang, 2008), with the peak incidence for common disorders occurring during adolescence (Paus, Keshavan, & Giedd, 2008). While some disorders (e.g., depression) typically develop during adolescence, others (e.g., attention deficit disorder) may have an earlier onset, but remain undiagnosed due to developmental context or limitations in screening and assessment. Childhood and adolescence provide critical periods for prevention, early detection, and intervention to promote child mental and behavioral health . Advances in brain imaging (Giedd J., Raznahan A., Alexander-Bloch A., Schmitt E., Gogtay N., & Rapoport J.L. ,2015), neuroscience (Casey, Getz, & Galvan, 2008; Luciana & Collins, 2012; Strang, Chein, & Steinberg, 2013) and behavioral science (Albert, Chein, & Steinberg, 2013; Smith, Chein, & Steinberg, 2013) have shown that there are critical environmental and genetic developmental influences on child and adolescent mental health, across biological, socioemotional, and behavioral domains ³. For example, early childhood is a period in which essential skills for self-regulation begin to develop (Berger, 2011; Diamond, 2013; Skinner & Zimmer-Gembeck, 2009), while adolescence is a period in which numerous risks become salient (National Research Council and Institute of Medicine , 2011), such as increased vulnerability to sensation-seeking, risk-taking behaviors, and susceptibility to peer influence. This can result in, among other things, enhanced vulnerability to substance use and addiction (Chambers, Taylor, & Potenza, 2003), including opioids (Wall et al., 2018). Moreover, research has identified multiple pathways and several risk factors leading to the development of mental and behavioral disorders in children and adolescents (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013; Frick, 2012; Latimer et al., 2012; Reiss, 2013). Disorder presentations are affected by biological determinants, environmental influences and genetics, including prenatal development and exposures and subsequent nutrition, in an interplay that is multi-determined and complex (Dunn et al., 2011; Tercyak, 2010). For example, research in epigenetics has shown that environmental and social factors (such as prenatal substance abuse, lead, pesticides, and other common, everyday exposures) alter gene expression, and experience interacts with genetic predisposition (Szyf, 2009). Clinicians and psychological scientists recognize that the etiological factors and behavioral expression of childhood disorders often overlap and interact, and co-morbidities are common. Some conditions, particularly developmental and intellectual disabilities, render children and adolescents vulnerable to under-diagnosis of co-morbid mental health and health problems (“diagnostic overshadowing”) (Matson & Williams, 2013).

Different pathways can progress to either mental and behavioral health symptoms or a diagnosable mental and behavioral disorder. These pathways involve multiple and interacting risk factors (described below)³ that influence periods of vulnerable development (Frick, 2012, 2016). Psychological and psychiatric research has found these factors to be interrelated in the development of a range of psychological problems, including disruptive behavior disorders (attention deficit hyperactive disorder, oppositional defiant disorder, and conduct disorder), depression and mood disorders, anxiety, posttraumatic stress disorders, obsessive compulsive disorders, eating and feeding disorders, schizophrenia, autism spectrum disorder, and intellectual disabilities (World Health Organization, 2018). Importantly, some mental health conditions with an onset during childhood are associated with heightened mortality (e.g., developmental disabilities, Hirvikoski, et al., 2016; mood disorders, Goldstein, 2009).  

Structural Determinants of Mental and Behavioral Health

Environmental risk factors that function as structural determinants of health include socioeconomic status, adverse and risky environmental conditions, and educational opportunities and outcomes. Low socioeconomic status (SES), indicated by lower household income, educational status, and poverty, is associated with greater risk of developing a mental and behavioral disorder than children and adolescents of middle or high SES (APA, 2018b; Reiss, 2013). Although SES is viewed as a family characteristic (human capital), low SES is often associated with structural and community level characteristics, such as systemic racism and oppression that drive policies that force families into under-resourced and unstable conditions. For example, children in lower SES families often receive inadequate physical and mental health care, leading to higher risk for mental and behavioral health problems and psychological disorders (e.g., Reiss, 2013; Russell, Ford, Williams, & Russell, 2016; Yoshikawa, Aber, & Beardslee, 2012).

Inadequate and inequitable educational opportunities and poor educational attainment are both risk factors for the development of psychological disorders and an outcome of serious mental and behavioral health problems in childhood and adolescence. For example, lower parental education is associated with development of mental and behavioral disorders in their children, likely related to low SES. Poor parental educational attainment often limits educational opportunities for the child and is related to the child's mental and behavioral health status. In contrast, positive academic performance is a strong indicator of subsequent positive life course outcomes (e.g., employment) as well as underrepresentation in psychiatric populations, drug use, school dropout and subsequent legal trouble (Farn & Adams, 2016).

Additionally, when children have a mental and behavioral health disorder, they often develop academic impairments or difficulties leading to educational underachievement due to frequent absences, higher rates of suspension or expulsion, or failure and drop out from high school (Breslau, Lane, Sampson, & Kessler, 2008; Russell, Ford, Williams, & Russell, 2016; Veldman, Bültmann, Almansa, & Reijneveld, 2015; Veldman, et al., 2015).

Risk factors in the environment, such as prenatal exposure to toxins including maternal cigarette smoking and alcohol use, chemical contaminants in the environment, and maternal stress, can influence development of mental and behavioral health disorders in infancy, childhood, and adolescence (Latimer et al., 2012; Frick, 2016). Later in development, psychosocial environment conditions (such as inadequate child care, ineffective family discipline, family disruption, deviant peer influences, childhood trauma from maltreatment, discrimination, family separation, or disasters, and neighborhoods with exposure to violence) influence the development of psychological disorders (Benner et al., 2018; Frick, 2012, 2016; Kearney, Wechsler, Kaur, & Lemos-Miller, 2010; Latimer et al., 2012).

Additionally, research shows that toxic stress (prolonged exposure to trauma and the biological stress response) impacts early brain development and later brain function, including executive functions such as control over emotions and impulses (APA, 2018b; Center on the Developing Child, 2014; Shonkoff & Gardner, 2012). A landmark study documented the profound impact of adverse childhood experiences on later adult health outcomes (Felitti et al., 1998), and subsequent research has clarified that this lifelong effect is due to significant changes in the nervous, endocrine and immune systems from prolonged exposure to the stress response (Danese & McEwan, 2012). In short, health across the lifespan is impacted by early childhood experiences (Conti & Heckman, 2013; Halfon & Hochstein, 2002; Halfon, Wise, & Forrest, 2014). However, research shows that the impact of environmental risk factors can be lessened or even prevented through building resilience (Masten, 2014), which, in turn, can be promoted through prevention and early intervention (Center on the Developing Child, 2015; Leslie et al., 2016). Moreover, reducing environmental risk factors has the potential to promote emotional health early in the life cycle (Center on the Developing Child, 2015).

Mental and Behavioral Health Disparities

Although all children and families may have difficulty accessing and utilizing adequate and effective mental and behavioral health services, low SES and minority children and adolescents have an even greater difficulty in receiving quality mental and behavioral health care. Minority stress and adverse experiences influence mental and behavioral health within oppressed populations, such as defined by gender, race and ethnicity, gender identity and sexual orientation, immigration status, physical, developmental, and intellectual disabilities, or chronic medical conditions.

Mental and behavioral health challenges in children and adolescents vary significantly by race and ethnicity, with higher rates of moderate and severe challenges among Hispanics and African Americans than among non-Hispanic Whites (Alegría, Green, McLaughlin, & Loder, 2015; Kataoka, Zhang, & Wells, 2002). Studies show that in comparison to their non- Hispanic White counterparts, racial/ethnic minority adolescents have similar or lower rates of mental and behavioral health challenges (Chatterji, Alegría, & Takeuchi, 2009; Kessler et al., 2005). However, while racial/ethnic minority adolescents do have similar rates, the course of mental and behavioral health challenges appears to be more persistent for them than for their non-minority counterparts (Chatterji, Alegría, & Takeuchi, 2009; Kessler et al., 2005). A recent report on mental health disparities identified four determinants of racial/ethnic minority mental health burden in children and adolescents (Alegría, Green, McLaughlin, & Loder, 2015). First, socioeconomic status, which can impact all children (as noted above) but disproportionately disadvantages racial/ethnic minority children, has been linked with material deprivation, perceived minority status, and higher levels of family stress, which contribute to mental health disparities (Dennis et al., 2003; Melchior et al., 2009). Second, family structure, such as single parent homes and step- families, contributes to mental health disparities through increased exposure to adverse childhood experiences (Wang, 2004), early transition to adult roles (Molina, Alegría, & Chen, 2012), and burdened parental capacities (Dennis et al., 2003; Shonkoff et al., 2012). Third, as noted above, adverse childhood experiences, particularly early and chronic exposure, have a negative impact on lifelong health (Shonkoff et al., 2012). Finally, neighborhood and social stress contribute to mental and behavioral health disparities via residential segregation, economic disadvantage, mobility, and violence and environmental toxicity (Sampson, Morenoff, & Gannon-Rowley, 2002).

In addition to the mental and behavioral health burden experienced by racial/ethnic minority children and adolescents, significant barriers exist in their access to and utilization of mental and behavioral health services (Austin & Wagner, 2010). For example, attitudes and beliefs about mental and behavioral health, due to concerns about stigma, can impact racial and ethnic minority families' decisions to seek treatment for their children (APA, 2017a; Turner, Jensen-Doss, & Heffer, 2015). Overall, racial/ethnic minority youth are less likely to receive services for internalizing challenges than non-Hispanic White youth (Gudiño, Lau, McCabe, & Hough, 2009). In addition, there are fewer mental and behavioral health services in low-income, racially segregated neighborhoods (Alegría, Vallas, & Pumariega, 2010 ). Even when services do exist, racial/ethnic minority children are less likely to receive quality care than their White, non-Hispanic counterparts (Alegría, Green, McLaughlin, & Loder, 2015), which is why the development of culturally appropriate, evidence-based mental and behavioral health promotion, prevention, and early intervention programs are so imperative.

Like race and ethnicity, gender also serves as a determinant of mental and behavioral health. Risk factors for experiencing mental and behavioral health difficulties may affect girls and boys differently. One such risk factor is exposure to violence. Girls have an increased risk of experiencing sexual abuse and assault at any age; whereas boys have an increased risk of experiencing physical violence and exposure to gang violence ( Brown & Bzostek, 2003; Kelly et al., 2012; Turner, Finkelhor & Ormrod, 2006) . During childhood, boys are more likely to be associated with and be treated for externalizing symptoms, whereas, girls are more likely to be associated with internalizing symptoms, which can go unrecognized and untreated, often due to gender bias in diagnosing (Green, Clopton & Pope, 1996; Merikangas et al., 2011; Seedat et al., 2009; World Health Organization, International, 2018). Prepubescent girls and boys have similar rates of depression, until adolescents, when girls are twice as likely to experience depression than are boys (Nolen-Hoeksema & Girgus, 1994 ). Moreover, girls are at greater risk of poor mental health due to gender-based violence, low income and income inequality, low social rank, and socioeconomic disadvantage ( Mendelson et al., 2008; World Health Organization, International, 2018). However, boys are less likely than girls to access care or to seek help due to stigma, which is even greater at the intersection of race and gender for Black adolescent males (Lindsey, Joe & Nebbitt, 2010).

Likewise, lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth face similar mental and behavioral health disparities (Cohn & Leake, 2012; Eisenberg & Resnick, 2006; Mustanski, Garafalo & Emerson, 2011). According to the Minority Stress Model (Hendricks & Testa, 2012; Meyer, 2003), due to stressors associated with status, discrimination, prejudice, social stigma, internalized stigma, rejection, and/or victimization, LGBTQ individuals are at an increased risk for mental and behavioral health problems and poorer physical health as compared to their cisgender heterosexual counterparts (Fredriksen-Goldsen et al., 2014), such as higher reported rates of anxiety and depression, low self-esteem, engaging in self-injurious behaviors, suicide, substance use, homelessness, and eating disorders (APA & National Association of School Psychologists, 2015). According to the Safe and Supportive School's Project on Youth at Disproportionate Risk, LGBTQ adolescents are more likely to engage in sexual risk- taking behaviors (e.g., earlier age at first sexual contact, engaging in unprotected sex, more lifetime and recent sex partners, and drinking alcohol or using other drugs prior to last sexual contact) that may impact mental health (APA, 2018a). Furthermore, LGBTQ students are more likely to face harassment, bullying, and a higher prevalence of dating violence compared to their heterosexual and/or cisgender peers, which can lead to suicidal thoughts or attempts and lower academic achievement (APA, 2018a; Russell et. al., 2011). They are also less likely to access and utilize health care services, especially if the provider lacks the necessary tools and sensitivity to provide comprehensive care and are uncomfortable having discussions about sexuality and diversity in sexual orientation and gender identity with adolescents (Coker, Austin, & Schuster, 2010).

Similarly, children and adolescents with developmental and physical disabilities and chronic medical conditions can face mental and behavioral health challenges. Mental and behavioral health disparities can occur within these populations due to discrimination, attitudinal and physical barriers, abuse and neglect, and lack of accessible and disability-sensitive services (APA, 2011). Although more attention is being paid to disability issues within graduate education and training related to children's mental and behavioral health (e.g., pediatric psychology), more needs to be done to prevent mental and behavioral health disparities within these specific populations.

Finally, it is important to appreciate the magnified effects of intersectionality (i.e., intersecting identities and multiple minority status, such as being a person of color as well as female, a gender identity and sexual orientation minority, an immigrant or a person with a disability) on mental and behavioral health and disparities.

Evidence-Based Practices

The field of psychology has pursued a primary role in the promotion of mental and behavioral health and the development of evidence-based prevention and intervention programs for children (National Research Council and Institute of Medicine, 2009a). However, access to, and utilization of, high-quality mental and behavioral health care, programs, and services lags significantly behind the needs of children and families, particularly in low-income communities and among children of minority backgrounds (Alegría, Green, McLaughlin, & Loder, 2015; Alegría Vallas & Pumariega, 2010 ; Atkins, Graczyk, Frazier, Abdul-Adil, 2003; Austin & Wagner, 2010; Kataoka, Zang& Wells, 2002 ). The effects of lack of access and utilization can be seen in the annual cost of mental, emotional, and behavioral disorders in children, and is estimated at $247 billion. Childhood mental and behavioral health disorders account for the largest category of spending of health dollars for children (AHRQ, 2012 ), with additional costs in special education, child welfare and juvenile justice. This expense can be mitigated through the implementation of evidence-based prevention and intervention programs, particularly early in childhood – beginning with infant mental health promotion and parenting support. At least sixteen family-focused prevention programs have been widely tested and shown to be effective (Blueprints, 2018), and several have been shown to be cost-effective as well (Washington State Institute for Public Policy, 2015)⁴. Evidence-based prevention and intervention can also have significant investment returns in the long-term labor market, with increased individual earnings and reduced welfare dependence (Independent Evaluation Group, 2015).

Prevention and early intervention programs that are multiyear are fundamental in early childhood. Interventions that target school readiness, social-emotional skills, behavioral concerns, and attachment positively impact children’s IQ, academic achievement, language development, self-regulation, and attachment to caregivers in the short-term, while increasing safety behaviors and decreasing the likelihood of the development of specific mental and behavioral health problems and substance use into adulthood (Anderson, et al., 2003; Independent Evaluation Group, 2015; Mountain, Cahill & Thorpe, 2017; Neil & Christensen, 2009). These interventions should take place early in child development; target risk and protective factors, rather than disorders; and promote change across multiple environments (home and school) (National Research Council and Institute of Medicine, 2009a). 

Many interventions have shown efficacy in research settings and effectiveness in community-based settings, but the frequency with which evidence-based practices are employed is low, despite evidence of their effectiveness among youth (APA Presidential Task Force, 2006; APA Task Force on Evidence-Based Practice for Children and Adolescents, 2008; Kazak et al., 2010; Weisz et al., 2006). Evidence-based practice in psychology (EBPP)⁵, which is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (APA Presidential Task Force, 2006; Levant, 2005), has garnered increased attention in the context of mental and behavioral health interventions among youth (e.g., APA Task Force on Evidence-Based Practice for Children and Adolescents, 2008; Kazak et al., 2010)⁶.

At the systems level, important factors to consider for improving dissemination and implementation, as well as promoting mental and behavioral health, include the settings in which prevention and early interventions take place (APA Task Force on Evidence-Based Practice for Children and Adolescents, 2008; Kazak et al., 2010; Southam-Gerow et al., 2012). Despite lower usage of evidence-based practices among youth and community-based settings, literature reviews have indicated that there are numerous evidence-based practices for children and adolescents for a variety of presenting conditions, including anxiety, attention difficulties, depression, conduct disorders, traumatic stress, substance use, eating problems, and mental and behavioral health diagnoses and problems related to developmental disabilities (Breland- Noble, Al-Mateen & Singh, 2016; Breland-Noble, Burriss & Poole, 2010; Eyberg, Nelson & Boggs, 2008; Flay et al., 2005; Weisz, Doss & Hawley, 2005; Weisz, Jensen-Doss & Hawley, 2006)⁶.  Adaptations of these evidence-based practices should be considered, especially in terms of client characteristics, developmental modifications, culture and other contextual processes, and family preferences (cf., Chorpita & Daleiden, 2009; Roberts & James, 2008; Roberts, Blossom, Evans, Amaro & Kanine, 2017). Cultural attunement, the practice of developing new interventions specifically for minority groups, is a more nascent area that promises to improve a tailored approach to serving minorities (Falicov, 2009). 

Barriers to successful implementation of evidence-based practice in community clinical settings involve multiple domains, including the child level (e.g., youth in community settings have higher levels of comorbidity and contextual risk, as well as greater levels of ethnic and socioeconomic diversity than those treated in research settings); the clinician level (e.g., reservations about applicability or utility of evidence-based practices); and the system level (e.g., availability of resources, training, or supervision) (Roberts et al., 2017; Southam-Gerow, Rodriguez, Chorpita & Daleiden, 2012; Whaley & Davis, 2007). Moreover, research on evidence-based practice often includes samples that might not generalize to clients seen in community-based settings (Kazak et al., 2010; Southam-Gerow et al., 2012; Weisz et al., 2006; Whaley & Davis, 2007).

Currently it takes many years for any original research to inform practice, creating an additional barrier in bridging the research to practice gap (e.g., Grant, Green, & Mason, 2003). Although significant issues remain with extensively implementing evidence-based interventions in community-based settings (Flay et al., 2005; Lochman et al., 2009; Southam-Gerow et al., 2012), numerous implementation frameworks have been developed (Albers et al., 2017). Implementation frameworks involve multiple factors, including stages, collaboration, key stakeholders across settings and domains, training, and supervision.  Yet more work needs to be done to move from the current, comprehensive implementation frameworks towards a more flexible, modular approach (Albers et al., 2017; Breland- Noble, Burriss, & Poole, 2010). It would be helpful to research and understand barriers to implementation and sustainability (e.g., staff turnover, resources) by evaluating the most effective means of gaining support from key stakeholders and how to address concerns with adopting evidence-based practice at the clinician and contextual levels (e.g., APA Task Force on Evidence-Based Practice for Children and Adolescents, 2008; Kazak et al., 2010; McHugh & Barlow, 2010; Southam-Gerow et al., 2012). Dissemination and implementation of these evidence-based practices in alternative and real-world settings, such as community- based settings, needs to increase (APA Task Force on Evidence-Based Practice for Children and Adolescents, 2008; Beidas & Kendall, 2010; Beidas et al., 2012; Kazak et al., 2010; Whaley & Davis, 2007).

To increase society’s capacity to serve periodic and subclinical-level child mental and behavioral health needs, mental and behavioral health should be addressed where children live, play, work, pray, and grow (Society for Research in Child Development, 2009; Tolan & Dodge 2005). The mental and behavioral health treatment enterprise needs to be interdisciplinary in order to fully understand and address the complex issues families face. Partnering and bringing together different sources of knowledge and expertise (both traditional and nontraditional providers), with the goal of promoting child mental and behavioral health and addressing mental and behavioral health problems, is key to influencing change in public understanding of, and attitude towards, child mental and behavioral health. Beginning in infancy, collaborations across systems, integrated mental health services, and parenting consultations, where all children and families access services (i.e., primary/specialty care, schools, early childhood education, child care, and home visiting programs) are essential (e.g., Adams, Hinojosa, Armstrong, Takagishi & Dabrow, 2016; Biel, Anthony, Mlynarski, Godoy & Beers, 2017; Kaliebe, 2017; Splett & Maras, 2011; Woltmann et al., 2012; Yu, Kolko, & Torres, 2017)). Providing services to children in school is especially important due to the link between good student health, mental and behavioral health, and academic success (Hass & Fosse, 2008). The data shows that most children receive mental health services at school (Farmer et al., 2003; Rones & Hoagwood, 2000). It is also critical to ensure smooth transitions from pediatric to adult health and mental and behavioral health care and social services, particularly for adolescents with chronic conditions and/or developmental disabilities (National Research Council and Institute of Medicine, 2009b; Institute of Medicine and National Research Council, 2015).  Additionally, in order to reduce health disparities, more research is needed to examine implementation of mental and behavioral health promotion, prevention, and intervention programs across diverse settings that utilizes screening to identify risk, and that tests the outcomes of culturally appropriate adaptations to evidence-based programs.

Child and Adolescent Mental and Behavioral Health Workforce 

Education and training are needed for those who work with young children and families in various settings (i.e. education, medical and mental health care, rural communities, faith-based services) about the importance of childhood mental and behavioral health, its importance in healthy development and social/emotional development (Society for Child and Family Policy and Practice, 2013), and the availability of evidence-based prevention and intervention practices. The lack of availability and limited access to mental and behavioral health care and services is especially evident within rural areas due to distance, transportation, and a shortage of mental and behavioral health providers working within these areas (National Academy of Sciences, 2017). To meet the needs of rural populations, there needs to be an increase in mental and behavioral health workers who are specifically trained and willing to work in rural populations (National Academy of Sciences, 2017). Additionally, in order to have culturally appropriate adaptations, the diversity of the mental and behavioral health (including psychology) workforce needs to be addressed.  While the ethnic and racial diversity of the U.S. population continues to grow, the psychology workforce has largely remained majority White, with less than 12 percent being from diverse racial and ethnic groups (APA, 2017b), leading to a substantial shortage of racial/ethnic minority providers of mental and behavioral health services (SAMHSA, 2016). It is important to have ethnically diverse and competent providers, educators, and researchers within the field, in order to both meet the needs of the public and uphold psychology’s commitment to social justice (Maton et al., 2006; Vasquez & Jones, 2006).  It is equally important to ensure that providers engage in culturally sensitive assessment and intervention (APA, 2017c; Turner et al., in press).  The lack of providers from diverse racial and ethnic groups influences disparities in prevention, assessment and treatment among racial and ethnic minority populations (e.g., APA, 2017c; Turner et al., in press). 

Not only is it important to have diversity in terms of race and ethnicity, it also necessary to encourage diversity in terms of gender, disability status, sexual orientation, and gender identity, in order to truly meet the needs of a diverse population. Additionally, professional education and training is needed to address gender-specific concerns, including provision of clinical services, efforts to counter biased policy, efforts to highlight and remove barriers to psychological well-being and to reduce bias based on perceived gender. The literature notes that client-therapist matching may be important to rapport and intervention success, therefore increasing the diversity of the profession is important (e.g., Turner, Malone, & Douglas, in press; Vasquez & Jones, 2006). Policy efforts at the university, state, and national level are needed to increase the number of psychologists from diverse groups to address equity, fairness, and services to the public (e.g., Turner & Turner, 2015; Vasquez & Jones, 2006). 

To increase diversity within the field, there needs to be more diversity within the pool of students pursuing higher degrees in the field of psychology (Turner & Turner, 2015; Vasquez & Jones, 2006). To improve the pipeline, academic support, and recruitment and retention of these students, diverse faculty are important at the undergraduate and graduate level (Maton, Kohout, Wicherski, Leary & Vinokurov, 2006; Vasquez & Jones, 2006). However, research shows that recruitment and retention are influenced by lack of financial resources, limited peer-faculty support, and mis-match between the student and doctoral programs (e.g., Callahan et al., 2018; Evans & Cokley, 2008; Turner & Turner, 2015; Vasquez & Jones, 2006; Yeo, Erickson Cornish & Meyer, 2017).

Childhood mental and behavioral health is essential to health and wellbeing across the lifespan. While psychology has made substantial contributions to promoting children’s mental and behavioral health, much remains to be done. Structural determinants of mental and behavioral health, limitations in access to, and implementation of, evidence-based prevention and treatment practices, and workforce and training needs persist. Without renewed attention from psychology, mental and behavioral health problems, disparities, and societal costs will continue.

¹ The term child mental and behavioral health, as used in this resolution, includes mental, social, and emotional health of all infants, children and adolescents, including those with developmental disorders, physical disabilities, and chronic medical conditions. This definition contrasts with the notion of child mental illness, in that mental illness denotes a condition or disorder that meets DSM/ICD criteria. This definition is consistent with the Report of the Surgeon General's Conference on Children's Mental Health (2000) which states, “mental health is a critical component of children's learning and general health.” It is also consistent with the World Health Organization (WHO) (2014) definition: “Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.”

² The Child and Adolescent Mental and Behavioral Health Resolution is a document relevant specifically to the United States, due to the science referenced in this document being largely based on US populations, which may or may not reflect on other countries.

³ See next section on Structural Determinants of Mental Health for examples of risk factors.

⁴ For more information on evidence-based prevention and treatment programs specific to children and families, please visit https://effectivechildtherapy.orgopens in new window , https://infoaboutkids.orgopens in new window and  https://pedpsych.org/ebp_resourcesopens in new window

⁵ This definition of EBPP closely parallels the definition of evidence-based practice adopted by the Institute of Medicine (2001, p. 147) as adapted from Sackett and colleagues (2000): “Evidence-based practice is the integration of best research evidence with clinical expertise and patient values.” The purpose of EBPP is to promote effective psychological practice and enhance public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention (APA, 2006).

Best available research refers to, “to scientific results related to intervention strategies, assessment, clinical problems, and patient populations in laboratory and field settings as well as to clinically relevant results of basic research in psychology and related fields. A sizeable body of evidence drawn from a variety of research designs and methodologies attests to the effectiveness of psychological practices. Generally, evidence derived from clinically relevant research on psychological practices should be based on systematic reviews, reasonable effect sizes, statistical and clinical significance, and a body of supporting evidence (APA, 2006).”

⁶ Also see articles in (1) Real-World Applications of Evidence-Based Interventions in Pediatric Psychology Special Issue of the APA Journal Clinical Practice in Pediatric Psychology , Vol. 2, No. 3, September 2014; (2) JCAAP Evidence-Based Series Article Collection, Journal of Clinical Child & Adolescent Psychology ; (3) Weisz, J.R., Doss, A.J., & Hawley, K.M. (2005). Youth psychotherapy outcome research: A review and critique of the evidence base. Annual Review of Psychology , 56, 337-363.

Adams, C. D., Hinojosa, S., Armstrong, K., Takagishi, J., & Dabrow, S. (2016). An innovative model of integrated behavioral health: school psychologists in pediatric primary care settings. Advances in School Mental Health Promotion, 9(3-4), 188-200.

Albers, B., Mildon, R., Lyon, A.R., & Shlonsky, A. (2017). Implementation frameworks in child, youth and family services – Results from a scoping review. Children and Youth Services Review, 81, 101-116.

Albert, D., Chein, J., & Steinberg, L. (2013). Peer influences on adolescent decision-making. Current Directions in Psychological Science, 22, 80-86.

Alegría, M., Green, J. G., McLaughlin, K. A., & Loder, S. (2015). Disparities in child and adolescent mental health and mental health services in the US. William T. Grant Foundation. https://philanthropynewyork.org/sites/default/files/resources/Disparitiesinchildandadolescenthealth.pdfopens in new window.

Alegría, M., Vallas, M., & Pumariega, A. J. (2010). Racial and ethnic disparities in pediatric mental health. Child and Adolescent Psychiatric Clinics of North America, 19, 759-774.

Agency for Healthcare Research and Quality. (2012). Household Component of the Medical Expenditures Panel Survey . https://meps.ahrq.gov/data_files/publications/st472/stat472.shtmlopens in new window.

American Academy of Pediatrics. (2014). Adverse Childhood Experiences and the Lifelong Consequences of Trauma. 

American Psychological Association. (2008). Task Force on Evidence-Based Practice for Children and Adolescents. Disseminating Evidence-Based Practice for Children and Adolescents: A Systems Approach to Enhancing Care. Washington, DC: American Psychological Association.

American Psychological Association. (2011). Task Force on Guidelines for Assessment and Treatment of Persons with Disabilities. Guidelines for Assessment of and Interventions with Persons with Disabilities. https://www.apa.org/pi/disability/resources/assessment-disabilities.

American Psychological Association. (2017a). Working Group for Addressing Racial and Ethnic Disparities in Youth Mental Health. Addressing the mental health needs of racial and ethnic minority youth: A guide for practitioners. https://www.apa.org/pi/families/resources/mental-health-needs.pdfopens in new window.

American Psychological Association. (2017b). Demographics of U.S. Psychology Workforce [interactive data tool]. https://www.apa.org/workforce/data-tools/demographics.

American Psychological Association. (2017c).  Multicultural Guidelines: An Ecological Approach to Context, Identity, and Intersectionality. https://www.apa.org/about/policy/multicultural-guidelines.pdfopens in new window.

American Psychological Association. (2018a). Safe and Supportive Schools Project: Youth at Disproportionate Risk. https://www.apa.org/pi/lgbt/programs/safe-supportive/disproportionate-risk.

American Psychological Association. (2018b). Working Group on Health Disparities in Boys and Men. Health disparities in racial/ethnic and sexual minority boys and men. https://www.apa.org/pi/health-disparities/resources/race-sexuality-men.

American Psychological Association & National Association of School Psychologists. (2015). Resolution on gender and sexual orientation diversity in children and adolescents in schools. https://www.apa.org/about/policy/orientation-diversity.

American Psychological Association Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285.

Anderson, L.M., Shinn, C., Fullilove, M.T., Scrimshaw, S.C., Fielding, J.E., Normand, J., Carande-Kulis, V.G., & the Task Force on Community Preventive Services. (2003). The effectiveness of early childhood development programs: A systematic review. American Journal of Preventive Medicine, 24(3S), 32-46.

Atkins, M. S., Graczyk, P. A., Frazier, S. L., & Abdul-Adil, J. (2003). Toward a New Model for Promoting Urban Children's Mental Health: Accessible, Effective, and Sustainable School-Based Mental Health Services. School Psychology Review, 32(4), 503-514.

Austin, A., & Wagner, E. F. (2010). Treatment attrition among racial and ethnic minority youth. Journal of Social Work Practice in the Addictions, 10 , 63-80.

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