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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities Summary Several decades of research have shown that the promise and potential lifetime benefits of preventing mental, emotional, and behavioral (MEB) disorders are greatest by focusing on young people and that early interventions can be effective in delaying or preventing the onset of such disorders. National priorities that build on this evidence base should include (1) assurance that individuals who are at risk receive the best available evidence-based interventions prior to the onset of a disorder and (2) the promotion of positive MEB development for all children, youth, and young adults. A number of promotion and prevention programs are now available that should be considered for broad implementation. Although individuals who are already affected by a MEB disorder should receive the best evidence-based treatment available, interventions before the disorder occurs offer the greatest opportunity to avoid the substantial costs to individuals, families, and society that these disorders entail. Most MEB disorders have their roots in childhood and youth. Among adults reporting a MEB disorder during their lifetime, more than half report the onset as occurring in childhood or adolescence. In any given year, the percentage of young people with these disorders is estimated to be between 14 and 20 percent. MEB issues among young people—including both diagnosable disorders and other problem behaviors, such as early drug or alcohol use, antisocial or aggressive behavior, and violence—have enormous personal, family, and societal costs. The annual quantifiable cost of such disorders among young people was estimated in 2007 to be $247 billion. In addition, MEB disorders among young people interfere with their abil-
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities ity to accomplish normal developmental tasks, such as establishing healthy interpersonal relationships, succeeding in school, and transitioning to the workforce. These disorders also affect the lives of their family members. A 1994 report by the Institute of Medicine (IOM), Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, highlighted the promise of prevention. In response to a subsequently burgeoning research base and an increasing understanding of the developmental pathways that lead to MEB problems, the Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism requested a study from the National Academies to review the research base and program experience since that time, focusing on young people. The Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults was formed under the auspices of the Board on Children, Youth, and Families to conduct this review (see Box S-1 for the complete charge). The 1994 IOM report reaffirmed a clear distinction between prevention and treatment. The current committee supports this distinction. The prevention of disability, relapse, or comorbidity among those with currently existing disorders are characteristics and expectations of good treatment. Although treatment has preventive aspects, it is still treatment, not prevention. The strength of prevention research using this concept of prevention, coupled with the need for focused research on risks prior to the onset of illness, warrants the field’s continued use of a typology focused on interventions for those who do not have an existing disorder. Interventions classified as universal (population-based), selective (directed to at-risk groups or individuals), or indicated (targeting individuals with biological markers, early symptoms, or problematic behaviors predicting a high level of risk) are important complementary elements of prevention. Going beyond the 1994 IOM report, we strongly recommend the inclusion of mental health promotion in the spectrum of mental health interventions. The volume and quality of research since 1994 have increased dramatically. Clear evidence is available to identify many factors that place certain young people or groups of young people at greater risk for developing MEB disorders, as well as other factors that serve a protective role. Box S-2 summarizes key advances since 1994. A number of specific preventive interventions can modify risk and promote protective factors that are linked to important determinants of mental, emotional, and behavioral health, especially in such areas as family functioning, early childhood experiences, and social skills. Interventions are also available to reduce the incidence of common disorders or problem behaviors, such as depression, substance use, and conduct disorder. Some interventions reduce multiple disorders and problem behaviors as well as
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities BOX S-1 Committee Charge Review promising areas of research that contribute to the prevention of mental disorders, substance abuse, and problem behaviors among children, youth, and young adults (to age 25), focusing in particular on genetics, neurobiology, and psychosocial research as well as the field of prevention science. Highlight areas of key advances and persistent challenges since the publication of the 1994 IOM report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. Examine the research base within a developmental framework throughout the life span, with an emphasis on prevention and promotion opportunities that can improve the mental health and behavior of children, youth, and young adults. Review the current scope of federal efforts in the prevention of mental disorders and substance abuse and the promotion of mental health among at-risk populations, including children of parents with substance abuse or mental health disorders, abused and neglected children, children in foster care, children whose parents are absent or incarcerated, and children exposed to violence and other trauma, spanning the continuum from research to policy and services. Recommend areas of emphasis for future federal policies and programs of research support that would strengthen a developmental approach to a prevention research agenda as well as opportunities to foster public- and private-sector collaboration in prevention and promotion efforts for children, youth, and young adults, particularly in educational, child welfare, and primary care settings. Prepare a final report that will provide a state-of-the-art review of prevention research. increase healthy functioning. While the evidence on the costs and benefits of interventions is limited, it suggests that many are likely to have benefits that exceed costs. In addition, a number of interventions have demonstrated efficacy to reduce risk for children exposed to serious adversities, such as maternal depression and family disruption. Like family adversities, poverty is a powerful risk factor, and its reduction would have far-reaching effects for multiple negative mental, emotional, and behavioral outcomes. Numerous policies and programs target poverty as a risk factor by giving priority to low-income children and their families and by promoting resources for healthy functioning of those living in poverty through, for example, early childhood education programs, programs to strengthen families and schools, and efforts to reduce neighborhood violence. The 1994 IOM report expressed hope that identification of the genetic
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities BOX S-2 Key Areas of Progress Since 1994 Evidence that MEB disorders are common and begin early in life. Evidence that the greatest prevention opportunity is among young people. Evidence of multiyear effects of multiple preventive interventions on reducing substance abuse, conduct disorder, antisocial behavior, aggression, and child maltreatment. Evidence that the incidence of depression among pregnant women and adolescents can be reduced. Evidence that school-based violence prevention can reduce the base rate of aggressive problems in an average school by one-quarter to one-third. Promising evidence regarding potential indicated preventive interventions targeting schizophrenia. Evidence that improving family functioning and positive parenting serves as a mediator of positive outcomes and can moderate poverty-related risk. Emerging evidence that school-based preventive interventions aimed at improving social and emotional outcomes can also improve academic outcomes. Evidence that interventions that target families dealing with such adversities as parental depression and divorce demonstrate efficacy in reducing risk for depression among children and increasing effective parenting. Evidence from some preventive interventions that benefits exceed costs, with the available evidence strongest for early childhood interventions. Evidence of interactions between modifiable environmental factors and the expression of genes linked to behavior. Greater understanding of the biological processes that underlie both normal brain function and the pathophysiology of MEB disorders. Emerging opportunities for the integration of genetics and neuroscience research with prevention research. Advances in implementation science, including recognition of implementation complexity and the importance of relevance to the community. determinants of mental illnesses was on the horizon. It is now recognized that most disorders are not caused by a small number of genes and that this area of research is highly complex. An emerging area of research involves the influence of the environment on the expression of a specific gene or set of genes, the importance of epigenetic modification of gene expression by experience, and direct injury to neural systems that give rise to illness. This exciting new knowledge has the potential to inform future preventive interventions. The future of prevention requires combined efforts to (1) apply existing knowledge in ways that are meaningful to families and communities and (2) pursue a rigorous research agenda that is aimed at improving both the quality and implementation of interventions across diverse communities.
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities PUTTING KNOWLEDGE INTO PRACTICE No concerted federal presence or clear national leadership currently exists to advance the use of prevention and promotion approaches to benefit the mental health of the nation’s young people. Infusing a prevention focus into the public consciousness requires development of a shared public vision and attention at a higher national level than currently exists. Recommendation: The federal government should make the healthy mental, emotional, and behavioral development of young people a national priority, establish public goals for the prevention of specific MEB disorders and for the promotion of healthy development among young people, and provide needed research and service resources to achieve these aims. (13-1) Mental, emotional, and behavioral disorders among young people burden not only traditional mental health and substance abuse programs, but also multiple other service systems that support young people and their families—most notably the education, child welfare, primary medical care, and juvenile justice systems. According to one estimate, more than a quarter of total service costs for children who have these disorders are incurred in the school and juvenile justice systems. Similarly, a quarter of pediatric primary care visits address behavioral issues. The cost savings of prevention programs likewise are experienced in a range of service systems. A national-level response therefore requires the creation of a designated entity with the authority to establish common prevention goals, to direct relevant federal resources, and to influence the investment of state, local, or private resources toward these goals as well as coordination and leadership across and within multiple federal agencies. Recommendation: The White House should create an ongoing mechanism involving federal agencies, stakeholders (including professional associations), and key researchers to develop and implement a strategic approach to the promotion of mental, emotional, and behavioral health and the prevention of MEB disorders and related problem behaviors in young people. The U.S. Departments of Health and Human Services, Education, and Justice should be accountable for coordinating and aligning their resources, programs, and initiatives with this strategic approach and for encouraging their state and local counterparts to do the same. (13-2) Federal resources should support the continued evaluation and refinement of programs to increase understanding of what works for whom and
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities when. The braiding of programmatic funding from service agencies, such as the Substance Abuse and Mental Health Services Administration, with evaluation funding from research agencies, such as the National Institute of Mental Health, would advance these efforts. Establishment of an ongoing national monitoring system that is capable of regular reporting on the incidence and prevalence of specific disorders, as well as the rates of exposure to key risk and protective factors, is needed to assess performance compared with national goals. Determining what is “evidence-based” is an important component of ensuring that these efforts have a positive impact on the lives of young people. Priority should be given to programs that have been tested and replicated in real-world environments, that have reasonable cost, and that are supported by tools that will help to implement key elements of the programs with fidelity. Federal and state agencies should not endorse programs that lack empirical evidence solely on the basis of general community endorsement. In turn, states and communities need to consider the relevance of available models to their own needs, priorities, and cultural contexts. They should evaluate programs and systems that they adopt, so as to continue to build the prevention knowledge base. Programs should also engage in and document the results of quality improvement efforts to continuously enhance program outcomes. Recommendation: States and communities should develop networked systems to apply resources to the promotion of mental health and prevention of MEB disorders among their young people. These systems should involve individuals, families, schools, justice systems, health care systems, and relevant community-based programs. Such approaches should build on available evidence-based programs and involve local evaluators to assess the implementation process of individual programs or policies and to measure community-wide outcomes. (13-3) Concurrently, concerted attention should be paid to developing a workforce that has the knowledge base and skill sets necessary to research, implement, and disseminate relevant interventions in diverse community contexts and cultures. Training and certification programs for the next generation of professionals working with young people should include the latest knowledge of the early trajectories of disorders and of prevention approaches in a life-course framework. Box S-3 provides a list of other specific recommendations relevant to putting knowledge into practice.
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities BOX S-3 Recommendations: 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. (12-1) 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 Safe and Drug Free Schools, the Office of Juvenile Justice and Delinquency Prevention) are experimentally evaluated through research funded by other agencies (e.g., the National Institutes of Health, the Institute of Education Sciences, the National Institute of Justice). This should include developing appropriate infrastructure through which evidence-based programs and practices can be delivered and evaluated. (12-2) 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. (12-3) 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 these communities. (8-2) 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. (11-4) (Also in Box S-5, Recommendations for Researchers) 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 the knowledge base of what works, for whom, and under what conditions. The definition of evidence-based should be determined by applying established scientific criteria. (12-4) 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 (e.g., the Diagnostic and Statistical Manual of Mental Disorders, the International Statistical Classification of Diseases) and (2) data that can provide indicators and trends for key risk and protective factors that serve as significant predictors for MEB disorders. (2-1)
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities 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. (2-2) Workforce Development 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 symptoms of MEB disorders. (12-6) 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. (12-7) 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. (12-8) NOTE: The first number refers to the chapter in which the recommendation appears; the second number references its order of appearance in the chapter. CONTINUING A COURSE OF RIGOROUS RESEARCH The National Institutes of Health (NIH) fund research related to the prevention of MEB disorders through multiple centers and institutes. A significant body of research now points to common trajectories across multiple disorders and highlights the potential for interventions to affect multiple disorders. However, no definition of prevention is shared across agencies, no NIH-wide planning or accounting of prevention spending exists, and there are no common research priorities. In addition, most NIH research centers address single disorders. The ability of prevention research to approach issues from a comprehensive developmental perspective would be aided by cross-institute dialogue and by coordinated funding for interventions that address co-occurring outcomes, common risk and protective factors, and shared developmental pathways.
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities Recommendation: The National Institutes of Health, with input from other funders of prevention research, should develop a comprehensive 10-year research plan targeting the promotion of mental health and prevention of both single and comorbid MEB disorders. This plan should consider current needs, opportunities for cross-disciplinary and multi-institute research, support for the necessary research infrastructure, and establishment of a mechanism for assessing and reporting progress against 10-year goals. (13-5) Continued investment in research can lead to interventions that will mitigate risks and strengthen protective factors prior to the onset of disorders and that will help to set young people on an appropriate developmental course. Substantial evidence has shown that the incidence of many disorders and problem behaviors can be reduced significantly, thereby justifying the need for dedicated efforts to refine these approaches. Recommendation: Research funders1 should establish parity between research on preventive interventions and treatment interventions. (13-4) The report makes a number of specific recommendations aimed at identifying areas of focus for future research in a 10-year plan that will inform future federal, state, and local initiatives (see Box S-4). The following focus areas should serve as the research priorities for both federal agencies and foundations, and they should stimulate prevention partnerships: Approaches to screening in conjunction with intervention. Screening can take place at multiple levels, including the level of the population to identify communities at risk (e.g., high-poverty neighborhoods), the level of groups to identify those at risk (e.g., children with depressed parents), and the level of individuals to identify those who have either behavioral symptoms or biological markers indicating the likelihood of developing a disorder (e.g., young children who exhibit highly aggressive behavior). However, screening without community acceptance and sufficient service capacity to respond to identified needs is of limited value. Models are needed that partner screening with implementation of evidence-based interventions. Implementation. Implementation has only recently been identified as an area of research in its own right. The effectiveness of state 1 The term “research funders” is used throughout the recommendations to refer to federal agencies and foundations that fund research on mental health promotion or prevention of MEB disorders.
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities BOX S-4 Recommendations: Continuing a Course of Rigorous Research Overall Research funders* should fund preventive intervention research on (1) risk and protective factors for specific disorders; (2) risk and protective factors that lead to multiple mental, emotional, and behavioral problems and disorders; and (3) promotion of individual, family, school, and community competencies. (4-3) 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 (e.g., disorders, academic outcomes), and (3) test the extent to which each prevention program is effective in different race, ethnic, gender, and developmental groups. (10-1) The National Institutes 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 (e.g., mental health, substance use, school success, contact with justice). (12-5) 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. (7-2) 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 mental, emotional, and behavioral problems and assess implementation of evidence-based preventive responses to identified needs. (8-1) 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. (10-2) Research funders should fund research and evaluation on (1) 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. (11-1) Research funders should fund research on state- or community-wide implementation of interventions to promote mental, emotional, or behavioral health
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities or prevent MEB disorders that meet established scientific standards of effectiveness. (11-2) Adaptation Research funders should prioritize the evaluation and implementation of programs to promote mental, emotional, or behavioral health or prevent MEB disorders in ethnic 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. (11-3) Neuroscience Linkages Research funders, led by 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. (5-1) 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. (5-4) 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. (5-2) Research funders, led by the National Institutes of Health, should fund research consortia to develop multidisciplinary teams with expertise in developmental neuroscience, developmental psychopathology, and preventive intervention science to foster translational research studies leading to more effective prevention efforts. (5-3) 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. (9-1). 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. (9-2)
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities 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. (4-1) 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. (4-2) Technology Research funders should support research on the effectiveness of mass media and Internet interventions, including approaches to reducing stigma. (7-3) 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. (7-4) NOTE: The term “research funders” is used to refer to federal agencies and foundations who fund research on mental health promotion or prevention of MEB disorders. and community-level implementation processes and approaches is one of the frontiers of future prevention research. Analysis of adaptation. Little research has addressed factors that either facilitate or impede the transfer or adaptation of evidence-based interventions that have been developed for a single setting to a range of other ethnic, linguistic, and cultural groups. Additional research is needed to ensure the availability of interventions that are culturally relevant and that have been informed by the nation’s many ethnic, linguistic, and cultural environments. Linkages with neuroscience. Environment and experience have powerful effects on modifying brain structure and function, including influences on the expression of genes and their protein products that can dictate or alter the course of development. Cross-disciplinary collaborations that formulate and test hypotheses concerning the
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities roles and interactions among multiple genetic and epigenetic influences on brain development may lead to strategies to tailor preventive interventions to specific individuals or groups of individuals at greatest risk. Economic analyses. The challenges of conducting economic analyses and the relative novelty of this type of analysis in the prevention field suggest the need for guidelines for conducting economic analyses (cost-effectiveness and cost-benefit analyses) as well as provision of incentives to encourage their inclusion in study designs. Evidence of the economic benefits of preventive interventions will make them more valuable to communities as they decide about the distribution of limited resources. Competencies. Competencies related to age-appropriate developmental tasks in the family, school, peer group, and community play an important role in mental health. The etiology and development of competencies need to be better understood. Methods to assess the relative value and effects of different types of competencies on development of and protection from disorders require attention. Use of technology. The Internet, mass media, and other current technologies (e.g., CD-ROMs) represent potential mechanisms to reach large segments of the population. Research in this area should be conducted to determine whether such media can be used effectively to promote mental health or to prevent disorders. Other research gaps. Despite dramatic increases in prevention research, significant gaps remain regarding populations and settings to be targeted. Given the modest effect sizes of some interventions, research funders are encouraged to support research to improve the breadth of the application and effectiveness of current evidence-based interventions and to develop new, more effective interventions. They should also direct researchers to measure outcomes over time, ideally across developmental periods, analyze multiple outcomes (including the effects on multiple disorders), and assess iatrogenic effects. Researchers in turn are encouraged to design interventions and evaluations that respond to these concerns (see Box S-5). Finally, the gap is substantial between what is known and what is actually being done. The nation is now well positioned to equip young people with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships that strengthen the social fabric. This can be achieved by refining the science and by developing the infrastructure and large-scale collaborative systems that allow the equitable delivery of population-based preventive approaches. We call on the nation to build on the extensive research now available by implement-
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities BOX S-5 Recommendations for Researchers Research and interventions on the prevention of MEB disorders should focus on interventions that occur before the onset of disorder but should be broadened to include promotion of mental, emotional, and behavioral health. (3-1) 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. (7-1) Researchers should include analysis of the costs and cost-effectiveness (and whenever possible cost-benefit) of interventions in evaluations of effectiveness studies (in contrast to efficacy trials). (9-3) 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. (11-4) ing evidence-based preventive interventions, testing their effectiveness in specific communities, disseminating principles in support of prevention, addressing gaps in the available research, and monitoring progress at the national, state, and local levels.