6
Family, School, and Community Interventions

Young people develop in the contexts of their family, their school, their community, and the larger culture, which offer multiple opportunities to support healthy development and prevent disorder. This chapter first reviews interventions in a variety of settings directed primarily at improving family functioning. These interventions target both expectant parents and families with children of different ages and are discussed in order of developmental stage. The chapter then examines interventions delivered in various school settings that seek to address risks for mental, emotional, and behavioral (MEB) disorders and problems or to foster positive development by focusing on change in developmental processes; this discussion is organized according to school level (e.g., early childhood education) and the developmental processes or behavior(s) targeted. Box 6-1, based on the studies discussed in the chapter, illustrates key results of family and school interventions. The section on community interventions describes approaches aimed at community-wide change. The final section offers concluding comments based on the information presented in the chapter, but does not include recommendations. Chapter 7 reviews preventive interventions that target specific MEB disorders, as well as those aimed at mental health promotion. The discussion in that chapter includes school and community interventions that specifically target substance abuse. Chapter 7 concludes with conclusions and recommendations that draw together the evidence from that and the present chapter.



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6 Family, School, and Community Interventions Y oung people develop in the contexts of their family, their school, their community, and the larger culture, which offer multiple opportunities to support healthy development and prevent dis- order. This chapter first reviews interventions in a variety of settings directed primarily at improving family functioning. These interventions target both expectant parents and families with children of different ages and are discussed in order of developmental stage. The chapter then examines interventions delivered in various school settings that seek to address risks for mental, emotional, and behavioral (MEB) disorders and problems or to foster positive development by focusing on change in developmental processes; this discussion is organized according to school level (e.g., early childhood education) and the developmental processes or behavior(s) targeted. Box 6-1, based on the studies discussed in the chap- ter, illustrates key results of family and school interventions. The section on community interventions describes approaches aimed at community- wide change. The final section offers concluding comments based on the information presented in the chapter, but does not include recommen- dations. Chapter 7 reviews preventive interventions that target specific MEB disorders, as well as those aimed at mental health promotion. The discussion in that chapter includes school and community interventions that specifically target substance abuse. Chapter 7 concludes with conclu- sions and recommendations that draw together the evidence from that and the present chapter. 57

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158 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-1 Results of Family and School Interventions Parenting Programs (examples: Incredible Years, Positive Parenting Program [Triple P], Strengthening Families Program: for Parents and Youth [SFP 10-14], Adolescent Transitions Program [ATP]) • Reduced aggressive, disruptive, or antisocial behavior • Improved parent–child interaction • Reduced substance abuse • Improved academic success Home Visiting Programs (examples: Nurse Family Partnership and Healthy Families New York) Home visiting programs that start during pregnancy have demonstrated: • Improved pregnancy outcomes, maternal caregiving, and maternal life course • Prevention of the development of antisocial behavior • Reduced physical abuse, aggression, and harsh parenting Comprehensive Early Education Programs (examples: Perry Preschool Program, Carolina Abecedarian Project, Child-Parent Centers) • Less child maltreatment • Less use of special education services, less grade retention, higher grade completion • Higher rates of high school graduation and college attendance • Fewer arrests by age 19, higher rates of employment, and higher monthly earnings Family Disruption Interventions New Beginnings Program, an intervention for families undergoing divorce: • Reduced odds of the child reaching diagnostic criteria for any mental disorder • Increased grade point average for adolescents • Reduced number of sexual partners reported by adolescents School-Based Programs Good Behavior Game, a first grade classroom management intervention: • Reduced disruptive behavior and increased academic engaged time • Reduced likelihood that initially aggressive students would receive a diagnosis of conduct disorder by sixth grade • Significantly reduced likelihood that persistently highly aggressive males would receive a diagnosis of antisocial personality disorder as a young adult

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159 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS • Prevention of suicidal ideation and suicide attempts • Significantly reduced risk of illicit drug abuse or dependence disorder at ages 19-21 Life Skills Training, a school-based substance use prevention program: • Significantly reduced drug and polydrug (tobacco, alcohol, and marijuana) use three years after the program • Strongest effects when delivered with fidelity—44 percent fewer drug users; 66 percent fewer polydrug users • Significantly reduced methamphetamine use up to 4.5 years later when com- bined with the Strengthening Families Program Linking Interests of Families and Teachers, a combined family–school interven- tion focused on skills and communication: • Reduced levels of aggressive behavior, less involvement with deviant peers and lower arrest rates, less use of alcohol and marijuana • For fifth graders, continued preventive effects three years later Fast Track, a multicomponent intervention in grades K-10: • Reduced self-reported antisocial behavior and significantly reduced incidence of conduct disorder for children at highest initial risk • Significantly reduced incidence of a diagnosis of attention deficit hyperactivity disorder for children at highest initial risk Seattle Social Development Project, a combined elementary grade parent– teacher training intervention: • Reduced diagnosable mental health disorders by age 24 and heavy alcohol use and violence by age 18 • Effects particularly strong for African Americans Adolescent Transitions Program, a parenting intervention delivered in schools: • Reduced rates of growth in tobacco, alcohol, and marijuana use between ages 11 and 17 and lowered likelihood of being diagnosed with a substance use disorder • Reduced rates of arrest

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60 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS PREVENTION AIMED AT FAMILY FUNCTIONING Families are the primary socializing agent of young people. Whether young people develop successfully depends substantially on whether fami- lies provide the physical and psychological conditions children need to acquire developmental competencies. This section begins with a review of the available evidence regarding family-focused prevention at each devel- opmental phase. It then moves to discussion of interventions that can affect family functioning and mental, emotional, and behavioral outcomes regardless of developmental phase. The section closes with a discussion of the effects of family economic well-being on diverse internalizing and externalizing disorders. Pregnancy, Infancy, and Early Development Preconception: Preventing High-Risk Pregnancies Among Teenagers Pregnancies among teenagers, particularly those younger than 16 years of age, are a risk factor for preterm birth, intrauterine growth retardation, and perinatal complications. Adolescent pregnancies are associated with single motherhood, low educational attainment, and low wages, all of which jeopardize children’s development (Ayoola, Brewer, and Nettleman, 2006). Empirical evidence that unintended pregnancies can be prevented by specific pregnancy prevention programs is limited. Higher-quality studies on average show discouraging outcomes for pregnancy, and most studies are pre-post or quasi-experimental. One meta-analysis of prevention strate- gies aimed at delaying sexual intercourse, improving use of birth control, and reducing the incidence of unintended pregnancy among adolescents found no evidence of beneficial effects for any targeted outcomes (DiCenso, Guyett, et al., 2002). Another found evidence of an effect on contraception and pregnancy but not on sexual activity (Franklin, Grant, et al., 1997). Although effective methods of intervening to prevent teenage pregnan- cies through family-, school-, or clinic-based programs are elusive, further research on the larger normative and cultural context for teenage sexual- ity may lead to approaches that are more effective. The recent decline in teenage pregnancies in the United States (Ventura, Mosher, et al., 2001), for example, suggests that opportunities to address malleable influences do exist. Fetal Development and Infancy Significant risks during fetal development for adverse neurobehavioral outcomes include genetic anomalies, poor maternal nutrition, maternal

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6 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS smoking and alcohol and drug use, exposure to neurotoxic substances, maternal depression or stress, low birth weight, and perinatal insults. Inter- ventions that prevent these conditions have the potential to prevent many subsequent problems for the child. For example, recent evidence suggests that reduced exposure of pregnant mothers to lead results in reduced total arrests and arrests for violent crimes of their children at ages 19-24 (Wright, Dietrich, et al., 2008). Universal preventive measures that have been adopted throughout the United States include the removal of lead from paint and gasoline. Another universal preventive measure (U.S. Environmental Protection Agency, 2004) has been warning pregnant women or those anticipating conception about the high methyl mercury content of fish at the top of the marine food chain. Prenatal exposure to this heavy metal has been linked to adverse cognitive and behavioral childhood outcomes (Gao, Yan, et al., 2007; Transande, Schechter, et al., 2006). However, some studies have reported increases in postpartum depression (Hibbeln, 2002) and reductions in children’s IQ (Hibbeln, Davis, et al., 2007) as a result of reduced seafood intake, sug- gesting that this area may warrant further study. Preterm Births and Prenatal Care The rate of preterm births in the United States has increased from approximately 8 to 12.5 percent over the past two decades, and attempts to prevent or reduce their frequency (such as by providing access to prena- tal care) have been unsuccessful (Institute of Medicine, 2007c). Reducing preterm births remains a significant opportunity for prevention of MEB disorders in childhood. Half of all mothers and infants in the United States are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal program that serves pregnant and lactating women and children up to age 5 (see http://www.fns.usda.gov/pdWIC_Monthly.htm). Participation in WIC has been associated with improved birth outcomes, such as longer pregnancies, fewer preterm births, decreased prevalence of anemia in childhood, and improved cognitive outcomes (Ryan and Zhou, 2006). Although it is likely that the WIC program contributes to the promotion of mental health of children and youth, the magnitude of this contribution is unknown. Peripartum Depression Changes in sleep, appetite, weight, energy level, and physical comfort in women during pregnancy and postpartum can cause significant emotional strain. Screening for peripartum (prenatal and postpartum) depression is

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62 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS routinely recommended for women in primary care (Pignone, Gaynes, et al., 2002; U.S. Preventive Services Task Force, 2002). Specific screening tools exist for peripartum depression, such as the Edinburgh Postnatal Depression Scale (EPDS) (Cox and Holden, 2003), one of several tools rec- ommended by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (Gaynes, Gavin, et al., 2005). Such screening tools as the EPDS have the potential to be modified to identify pregnant women with elevated symptoms of depression who would benefit from indicated interventions. In addition, some self-care tools can be useful as the first step in alleviating symptoms of depression (Bower, Richards, and Lovell, 2001). Such tools, commonly based on cognitive-behavioral therapy (CBT), have emerged in a variety of formats, including booklets, manuals, CD-ROMs, audiotapes, and videotapes (Blenkiron, 2001; Williams and Whitfield, 2001; Gega, Marks, and Mataix-Cols, 2004). CBT has a significant evidence base (e.g., Williams and Whitfield, 2001; Richards, Barkham, et al., 2003; Scogin, Hanson, and Welsh, 2003; Gega, Marks, and Mataix-Cols, 2004), and self-care tools have been successfully incorporated into stepped-care models of depression treatment in primary care settings (for patients with mild to moderate depression), with psychotherapy provided for those who fail to improve (Scogin, Hanson, and Welsh, 2003). Maternal Sensitivity and Infant Attachment Mother–infant attachment has been the focus of research and is a well- established influence on infants’ successful development (National Research Council and Institute of Medicine, 2000; see also Chapter 5). A meta- analysis of 51 studies that evaluated interventions to increase maternal sen- sitivity and infant attachment using randomized controlled designs found that on average, the interventions were moderately effective in enhanc- ing sensitivity (Bakersman-Kranenburg, van Ijzendoorn, and Juffer, 2003). A total of 23 of the studies used a randomized design to assess impact on attachment and demonstrated a slight effect; interventions focused on directly enhancing sensitivity were significantly more effective than other types of interventions. Home Visiting Home visiting is an intensive intervention that targets successful preg- nancies and infant development. In these highly variable programs, a nurse or paraprofessional begins visiting the mother during the pregnancy or just after birth and continues to do so through the first few years of the child’s life. The majority of programs provide parenting education, information

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6 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS about child development, social support to parents, encouragement of positive parent–child interactions, and social and health services. Some also provide case management services and health and developmental screening for children (Sweet and Appelbaum, 2004). Sweet and Appelbaum (2004) conducted a meta-analysis of experi- mental and quasi-experimental evaluations of 60 home visiting programs. Only a fourth of these programs included home visiting during pregnancy. The authors conclude that on average, families receiving home visiting did better than those in control conditions. Mothers were more likely to pursue education but did not differ in their employment, self-sufficiency, or wel- fare dependence. The programs produced better outcomes in three of five areas of children’s cognitive and social-emotional functioning. However, the authors also note that the significant variability across programs makes it difficult to evaluate them as a group. Aos, Lieb, and colleagues (2004) found that average benefits of the 25 programs reviewed exceeded costs. The home visiting program with the best experimental evaluations and strongest results to date is the Nurse-Family Partnership (NFP), which has been evaluated in three randomized controlled trials. NFP is unique in tar- geting only first-time mothers. The theory of change is that women may be more open to support and guidance during their initial pregnancies (Olds, Hill, et al., 2003), which may contribute to the strength of the program’s outcomes. This theory is supported by a randomized controlled trial of another home visiting program, which had a significant impact on first-time mothers’ positive caregiving but not on that of women who were already mothers (Stolk, Mesman, et al., 2007). In the first two trials (in New York and Tennessee), the program improved pregnancy outcomes, maternal care- giving, and the maternal life course and prevented the development of anti- social behavior. The third trial (in Colorado) showed benefits as well. NFP has other distinguishing features that may contribute to the strength of its outcomes. First, the program providers are nurses with both substantial training and credibility regarding pregnancy and infants. The Colorado trial experimentally evaluated the impact of nurses versus paraprofessionals and found that nurse visitation produced more benefits compared with the control condition (Olds, Robinson, et al., 2002, 2004). None of the other home visitation interventions reviewed by Gomby (1999) employed nurses as providers. Second, NFP uses well-established techniques to guide changes in specific behaviors, such as smoking, seeking an educa- tion, and getting social support. The focus on smoking in the New York study, in which more than 50 percent of mothers smoked, is especially noteworthy given the well-established relationship between smoking dur- ing pregnancy and children’s subsequent antisocial behavior and substance use (see Brennan, Grekin, et al., 2002; Wakschlag, Lahey, et al., 1997; Weissman, Warner, et al., 1999).

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64 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Since nurses who delivered the NFP trial interventions were also expected to deliver the program in the communities to which it would be disseminated, the trials had elements of effectiveness studies. However, the cost of training and the limited pool of nursing professionals in some com- munities may impede community-wide implementation. A randomized controlled study by DuMont, Mitchell-Herzfeld, et al. (2008) of the Healthy Families New York (HFNY) program suggests that the use of paraprofessionals can achieve prevention benefits when targeting women during their first pregnancy. The results of this study are consistent with those for NFP in at least two ways. First, like NFP, HFNY worked with young mothers enrolled during their pregnancy (DuMont, Mitchell- Herzfeld, et al., 2008). Second, HFNY had a greater impact on psycho- logically vulnerable mothers, results that parallel findings for NFP (Olds, Robinson, et al., 2004). Important differences were also reported. DuMont, Mitchell-Herzfeld, et al. (2008) found greater benefit from delivery of HFNY by paraprofes- sionals than was found in the NFP trial in Colorado (Olds, Robinson, et al., 2002, 2004). This result may be attributable to the larger number of cases in the HFNY study and the limited statistical power of the Colorado NFP trial (Olds, Robinson, et al., 2002). However, further research is needed to determine conclusively whether paraprofessional home visitors can achieve results comparable to those of nurse visitors. Early Childhood and Childhood Aggressive social behavior, which typically begins to emerge during childhood, is a key risk factor for progression of externalizing disorders (see Brook, Cohen, et al., 1992; Kellam, Ling, et al., 1998; Lipsey and Derzon, 1998; Robins and McEvoy, 1990; Tremblay and Schaal, 1996; Woodward and Fergusson, 1999) and also is a predictor of internalizing disorders (Kaltiala-Heino, Rimpela, et al., 2000; Keenan, Shaw, et al., 1998; Kellam, Brown, et al., 2008). There is now extensive evidence on interventions designed to help families develop practices that prevent the development of aggressive and antisocial behavior and its associated problems. These interventions focus on providing training in parenting skills. Seminal research on family interactions by Patterson and colleagues over the past 40 years has shown that harsh and inconsistent parenting practices contribute to aggressive and uncooperative behavior and that positive involvement with children and positive reinforcement of desirable behavior contribute to cooperative and prosocial behavior (e.g., Patterson and Cobb, 1971; Patterson, 1976, 1982). Building on the early parent- ing interventions by Patterson’s group (e.g., Patterson and Gullion, 1968;

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65 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS Patterson, 1969, 1974), a number of programs have emerged that target par- ents of children at different developmental stages, including childhood (e.g., Forgatch and DeGarmo, 1999; Webster-Stratton, 1990; Sanders, Markie- Dodds, et al., 2000), early adolescence (e.g., Dishion and Andrews, 1995; Spoth, Goldberg, and Redmond, 1999), and adolescence (Chamberlain, 1990; Henggeler, Clingempeel, et al., 2002). All of these programs teach and encourage parents to (1) use praise and rewards to reinforce desirable behavior; (2) replace criticism and physical punishment with mild and con- sistent negative consequences for undesirable behavior, such as time-out and brief loss of privileges; and (3) increase positive involvement with their chil- dren, such as playing with them, reading to them, and listening to them. The efficacy of interventions focused on parenting skills is well estab- lished (see Lochman and van-den-Steenhoven, 2002; Petrie, Bunn, and Byrne, 2007; Prinz and Jones, 2003; Serketich and Dumas, 1996). In addi- addi- tion, several meta-analyses report positive effects of such interventions across a range of child and parent outcomes for parents of young children (Barlow, Coren, and Stewart-Brown, 2002; Lundahl, Nimer, and Parsons, 2006; Serketich and Dumas, 1996; Kaminski, Valle, et al., 2008). Kaminski, Valle, and colleagues (2008) report the greatest effect sizes for programs that include parent training in creating positive parent–child interactions, increasing effective emotional communication skills, and using time-out and that emphasize parenting consistency. Many parenting programs have been shown in two or more experimental trials to produce positive behavioral outcomes. Two examples of parenting interventions with substantial empirical evidence are highlighted in Boxes 6-2 and 6-3. The Incredible Years (see Box 6-2), a combined parent–school intervention, has been tested as a selec- tive and indicated intervention for children with aggressive behavior and related problems that have not yet reached clinical levels. It also has been tested in effectiveness trials using indigenous family support personnel and is one of few interventions that has been tested by independent investiga- tors rather than the program developer. The Positive Parenting Program (Triple P) (see Box 6-3) is a multilevel intervention with universal, selec- tive, and indicated components. It recently demonstrated positive results when tested on a population-wide basis in Australia (Sanders, Ralph, et al., 2008). Both programs have also been evaluated as treatment interventions, with positive results for those diagnosed with specific disorders, such as attention deficit hyperactivity disorder (ADHD; e.g., Hoath and Sanders, 2002). Additional parenting interventions are highlighted in the next section. Interventions that combine training in parenting skills with school-based interventions are described later in the chapter.

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66 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-2 The Incredible Years Program: A Combined Parent–School Intervention The Incredible Years Program (Webster-Stratton, 1990) includes parent, teacher, and social skills training components. The parent-training program shows parents brief videotaped vignettes of parent–child interactions as examples of positive interactions and communication with their children, the value of praise and reward, and the use of time-out and other mild negative consequences. The program has been extensively evaluated in treating children with conduct disorders and in preventing further aggressive behavior and related problems in children whose behavior is not yet at the clinical level. It has been shown to improve parents’ use of positive parenting practices; to reduce harsh, critical parenting; and to reduce diverse problem behaviors (Gardner, Burton, and Klimes, 2006; Linares, Montalto, et al., 2006; Patterson, Reid, and Eddy, 2002; Reid, Webster-Stratton, and Beauchaine, 2001). These benefits have been shown for a variety of ethnic groups (Reid, Webster-Stratton, and Beauchaine, 2002; Patterson, Reid, and Eddy, 2002) and when provided by diverse professionals, including teachers, nurses, family support specialists, and social workers (Hutchings, Bywater, et al., 2007; Gardner, Burton, and Klimes, 2006). Barrera, Biglan, and colleagues (2002) evaluated the Incredible Years parenting program as one component of an intervention designed to prevent read- ing failure and the development of aggressive behavior problems among high-risk elementary schoolchildren. Children who received the intervention displayed less negative social behavior than controls. The program’s teacher training component focuses on effective preschool and elementary classroom management, while the social skills component teaches children these skills using dinosaur puppets (Dinosaur School). Gross, Fogg, et al. (2003) evaluated the individual and combined effects of the parent and teacher training for 2- and 3-year-old children in day care centers serving low-income minority families in Chicago. Parents who received the parent training had higher efficacy scores, were less coercive in their discipline, and behaved more posi- tively toward their children than did mothers in the control condition, although the effect on parent coerciveness was not sustained at one-year follow-up. Toddlers who were classed as at high risk for problem behavior at the outset of the study and who were in the parent or teacher training condition improved significantly more than children in the control condition; this improvement was maintained at one-year follow-up. Toddlers in the teacher plus parenting training condition did significantly worse on this measure than those in either the teacher training– or parent training–alone condition. Webster-Stratton, Reid, and Stoolmiller (2008) report on an evaluation of the teacher training combined with Dinosaur School. The study involved students in Head Start and first grade classrooms in schools that served children in poverty. Teachers who received the training used more positive classroom management strategies, and their students were rated as more socially competent, better at self-regulation, and having fewer conduct problems.

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67 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS BOX 6-3 Triple P: A Multilevel Parenting Intervention The Positive Parenting Program (Triple P) focuses on the general population, not just individual families, and has selected components tailored to at-risk groups (such as young single mothers) or children with behavioral problems. The program includes five levels of parenting guidance based on family needs and preferences. The universal level provides information via mass media about effective parenting and solutions to common childrearing problems. The second level provides brief advice to parents for dealing with specific concerns, such as toileting or bedtime problems; parents are typically reached through contact with primary health care providers, such as pediatricians. The third level provides skills training for parents who are having problems with children’s aggressive or uncooperative behavior. The fourth level (standard Triple P) provides up to 12 one-hour sessions on parenting skills for parents whose children have multiple behavioral problems, particularly aggressive behavior. The final level, enhanced Triple P, provides skills and support to deal with parental depression, marital discord, or other family challenges. Sanders, Markie-Dadds, et al. (2000) evaluated three variants of Triple P (enhanced Triple P, standard Triple P, and self-directed training) and a wait-list condition with families of preschoolers who were at risk of developing conduct problems. The two practitioner-assisted interventions were more effective than the self-directed training or the wait-list condition. At one-year follow-up, all three active intervention conditions had similar levels of change in directly observed disruptive behavior. Another randomized controlled evaluation of standard Triple P and enhanced Triple P likewise showed positive effects (Ireland, Sanders, and Markie-Dadds, 2003). Sanders, Pidgeon, and colleagues (2004) tested an enhanced version of Triple P that had an additional component to help parents deal with anger problems. This trial also demonstrated significant benefits. A randomized controlled study of the mass media component of Triple P (Sanders, Montgomery, and Brechman-Toussaint, 2000) indicated that children of parents who watched a 12-episode television series had significantly lower levels of disruptive behavior (based on parental reports), and parents expressed higher levels of competence. Prinz, Sanders, and colleagues (2009) recently reported a randomized trial of Triple P in 18 South Carolina counties that was accompanied by a media campaign. This study is noteworthy for being the first to show signifi- cant positive effects of a parenting intervention in an entire population. Early Adolescence Early adolescence is a developmental period during which the preva- lence of substance use, delinquency, and depression begins to rise. There is also evidence of an increase in the rates of teasing and harassment in middle school. Significant physical changes occur with the onset of puberty, along with social changes, including the transition from elementary school

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80 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS preschool years and family functioning when children were in elementary school. The Centers for Disease Control and Prevention’s (CDC’s) Commu- nity Preventive Services Task Force strongly recommends publicly funded, center-based, comprehensive early childhood development programs for low-income children ages 3-5. This recommendation is based on evidence of the programs’ effectiveness in preventing developmental delay, as assessed by improvements in grade retention and placement in special education (Anderson, Shinn, et al., 2003). Temple and Reynolds (2007) review the benefits of three comprehensive early education programs: the Perry Preschool Program and the Carolina Abecedarian project, both evaluated in randomized controlled trials, and the Child-Parent Centers (CPC), which employed a comparison condition. All three programs sought to improve educational attainment through a focus on cognitive and language skills and use of small class sizes and well- qualified teachers. The Perry Preschool Program and CPC included a parent intervention, but the Carolina Abecedarian project did not. All three programs conducted follow-up assessments into adulthood, which included at least 87 percent of study participants. Important aca- demic outcomes were found, including less use of special education services, less grade retention (for two of the programs), higher grade completion, a higher rate of high school graduation, and higher rates of college atten- dance. Other program effects included less child maltreatment (in the only program that assessed that outcome), fewer arrests by age 19 (two pro- grams), higher rates of employment (in the two programs that assessed this outcome), and higher monthly earnings (assessed by one program). A study of adults who participated in the Abecedarian project also dem- onstrated reduced levels of depressive symptoms (McLaughlin, Campbell, et al., 2007). Temple and Reynolds (2007) conclude that the benefits of these programs exceeded their costs. A meta-analysis by Aos, Lieb, and colleagues (2004) of these and other early childhood education programs draws a similar conclusion (see also Chapter 9). Although Head Start has been cited by CDC as an example of a feasible program that could diminish harm to young children from disadvantaged environments (Anderson, Shinn, et al., 2003), few experimental evaluations of the program have been conducted. Ludwig and Philips (2007) report only one recent randomized controlled trial of the program (Puma, Bell, et al., 2005) and one regression discontinuity design based on data from the 1970s and 1980s (Flay, Biglan, et al., 2005; Ludwig and Miller, 2007). Both studies showed that Head Start has some benefit in improving children’s cognitive functioning. The evidence from these studies, considered in the context of other research on the value of early childhood education, points to the likely value of universal access to Head Start for disadvantaged chil-

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8 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS dren. At the same time, given the magnitude of the program, the potential value of conclusive evidence of its effect, and the availability of rigorous experimental methods, it is surprising that more experimental evaluations have not been conducted. Several preschool classroom curricula are designed to improve teachers’ behavior management of classrooms by reducing child behavior problems and strengthening children’s social skills or executive functioning (or both). The Promoting Alternative Thinking Strategies (PATHS) curriculum (see Box 6-7) is an example of a curriculum that has been tested in both pre- school and elementary school settings. Elementary, Middle, and Secondary School Interventions Targeting Child Sexual Abuse As mentioned earlier, child maltreatment, including sexual abuse, is a potent risk factor for emotional and behavioral problems. Davis and Gidycz (2000) report on a meta-analysis of school-based programs aimed at teach- ing children to avoid and report sexual abuse. These programs led to sig- nificant improvement in child knowledge and skills related to sexual abuse prevention. The most effective programs included four or more sessions, active participant involvement (such as role play), and behavioral skills training. However, none of the studies examined effects on the prevalence of abuse, and it is difficult to draw conclusions about potential downstream effects of these programs on the risk for MEB disorders. Targeting Problem Behaviors, Aggression, Violence, and Substance Abuse Many of the target risk factors of preventive interventions are inter- related. In early elementary school, for example, both aggressive and with- drawn behaviors can co-occur, imparting much higher risk than aggressive behavior alone (Kellam, Brown, et al., 1983), and both risk factors are independently linked to concurrent and successive problems in concentra- tion, attention, and poor achievement. Depressive symptoms in this period are also associated with poor achievement (Kellam, Werthamer-Larsson, et al., 1991). Externalizing behavior across different social fields and deviant peer group contact in middle school predict later juvenile arrest and drug use, and much higher levels of risky sexual behavior are seen among those with both internalizing and externalizing problems (Dishion, 2000). The life course of those with multiple problem behaviors is especially negatively affected (Biglan, Brennan, et al., 2004). A variety of school-based interventions have been designed to address risk and protective factors associated with violence, aggression, antisocial

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82 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-7 Promoting Alternative Thinking Strategies: A Preschool and Elementary School Curriculum Promoting Alternative Thinking Strategies (PATHS) teaches elementary and preschool children about emotion, self-control, and problem solving. A series of evaluations of randomized controlled trials have reported program benefits for children. The PATHS curriculum (Kusche and Greenberg, 1994) has varied across studies as a function of the age of children, their abilities, and curriculum opportunities. Greenberg, Kusche, and colleagues (1995) report on a randomized controlled trial in which four elementary schools and 14 special education classrooms were randomly assigned to deliver or not deliver the curriculum to students in grades 2 and 3. The school-year curriculum consisted of 60 lessons on emotional and interpersonal understanding, including identifying and appreciating various affec- tive states, and how to control emotions. A Control Signals Poster, modeled after a stop sign with red, yellow, and green lights, taught students emotional control and problem solving in difficult social situations. Students learned to stop and try to calm themselves and think about how to handle the situation, how to implement their plan, and how to evaluate their conduct. Greenberg, Kusche, and colleagues (1995) found that PATHS increased the students’ ability to understand and articulate emotions. Special education students had a greater understanding of other people’s ability to hide their feelings and the fact that feelings can change. In a randomized wait-list controlled trial of a version of PATHS with deaf children in elementary grades, Greenberg and Kusche (1998) found that PATHS students performed significantly better on a number of cognitive, social, and emo- tional measures. Kam, Greenberg, and Kusche (2004) report on a randomized controlled trial of PATHS in which 18 special education classrooms were assigned to either the intervention or the control. Students received the intervention when they were in first or second grade and completed assessments annually for the following three years. Those who received the program had significantly fewer externalizing and internalizing problems than control students, as well as a greater decrease in depression. PATHS has also been evaluated as a universal intervention in the Fast Track study of the prevention of antisocial behavior. First grade students in schools (378 classrooms) in high-crime neighborhoods in four regions of the United States were randomized to receive or not receive a 57-lesson version of PATHS. Peer sociometric data indicated that PATHS classrooms had lower levels of aggression and hyperactive behavior and a more positive atmosphere, but they did not differ on any teacher ratings of classroom behavior (Conduct Problems Prevention Research Group, 1999b).

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8 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS behavior, and substance use, primarily in middle school group settings (see Chapter 7 for discussion of programs that specifically target substance use and abuse). Many of these interventions involve social skills training using cognitive components that alter perception and attributions or a curriculum designed to change behaviors to improve social relationships or promote nonresponse to provocative situations. Universal interventions are often designed to affect school structure; improve classroom management; or improve students’ relationships, self-awareness, or decision-making skills. Selective and indicated interventions tend to focus on skill development. A growing body of research shows that many negative outcomes, such as psychopathology, substance abuse, delinquency, and school fail- ure, have overlapping risk factors and a significant degree of comorbidity (Feinberg, Ridenour, and Greenberg, 2007). Emerging evidence suggests that some programs have positive effects on several of these outcomes (Wilson, Gottfredson, and Najaka, 2001). Numerous meta-analyses of school-based preventive interventions have been conducted, varying in the specific types of programs included, the age range of the interventions, and the target problems. All have reviewed one or more outcomes related to antisocial behavior, violence and aggression, or substance abuse and found significant but small to modest effects on measured outcomes. Although both universal (Centers for Disease Control and Prevention, 2007; Hahn, Fuqua-Whitley, et al., 2007) and selective/indicated interventions show positive effects, effect sizes tend to be greatest for high-risk groups (Wilson and Lipsey, 2006b, 2007; Beelman and Losel, 2006; Mytton, DiGuiseppi, et al., 2006; Wilson, Lipsey, and Derzon, 2003; Wilson, Gottfredson, and Najaka, 2001), and greater for improvements in social competence and antisocial behavior than in substance abuse. Meta-analyses provide support for the positive effects of behavioral interventions (Wilson and Lipsey, 2007; Mytton, DiGuiseppi, et al., 2006; Wilson, Gottfredson, and Najaka, 2001) as well as cognitively oriented interventions (Wilson and Lipsey, 2006a, 2006b). There is some indica- tion that programs combining behavioral and cognitive aspects can impact multiple outcomes, specifically social competence and antisocial behavior (Beelmann and Losel, 2006). Wilson, Lipsey, and Derzon (2003) found significant effects of school-based programs on aggressive behavior. Wilson and Lipsey (2007) conclude that program effects have practical as well as statistical significance and forecast that such programs would lead to a 25- 33 percent reduction in the base rate of aggressive problems in an average school. Few programs to date have focused on classroom or behavior man- agement. A meta-analysis that included two such programs found them to have a sizable impact on delinquency (Wilson, Gottfredson, and Najaka, 2001). There is strong evidence for the long-term effects of at least

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84 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-8 The Good Behavior Game: An Elementary School Universal Intervention Targeting Classroom Behavior The Good Behavior Game (GBG) is a simple universal program to reinforce appropriate social and classroom behavior in elementary school. The theory of the program is that reducing early aggressive behavior will change the developmental trajectory leading to multiple problems in later life. Classrooms are divided into teams, and each team can win rewards if the entire team is “on task” (e.g., fewer than a specified number of rule violations during the game period) or otherwise acting in accordance with previously stated teacher expectations. Rewards include extra free time, stars on charts, and special team privileges. The GBG has been tested in multiple trials, including some that measured long- term results. A review by Embry (2002) emphasizes the strength of the evidence and concludes that the GBG (1) dramatically reduced disruptive behavior and increased academic engaged time, and (2) had effects that have been replicated across elementary school grades, among preschoolers, and in other countries. Kellam and colleagues (Kellam, Werthamer-Larsson, et al., 1991; Kellam, Rebok, et al., 1994) evaluated the long-term impact of the GBG in a randomized controlled trial with 19 Baltimore schools that compared the program with a test of mastery learning among first graders (Block, 1984) and usual practice. The GBG reduced aggressive and disruptive behavior during first grade (Dolan, Kellam, et al., 1993; Kellam, Rebok, et al., 1994; Rebok, Hawkins, et al., 1996; Kellam, Ling, et al., 1998). By middle school, recipients of the GBG had lower rates of smoking (Kellam and Anthony, 1998), and those who had initially been aggressive had experienced less growth in aggressive behavior (Muthén, Brown, et al., 2002). Petras, Kellam, et al. (2008) used latent class analysis to assess the long-term (at ages 19-21) impact of the GBG on aggressive male behavior. The program significantly reduced the likelihood that persistently highly aggressive boys would receive a diagnosis of antisocial personality disorder as a young adult. It also pre- vented suicidal ideation and suicide attempts (Wilcox, Kellam, et al., 2008). Other analyses of outcomes at ages 19-21 showed that the GBG significantly reduced the risk of alcohol or illicit drug abuse or dependence (Kellam, Brown, et al., 2008) and use of mental health and drug services (Poduska, Kellam, et al., 2008); there were no effects on anxiety and depression. Aos, Lieb, and colleagues (2004) report that the benefits of the GBG exceed its costs. one classroom intervention, the Good Behavior Game (see Box 6-8), on aggression and mental health and substance abuse–related outcomes, particularly among boys. Preventive interventions can also have a positive effect on academic outcomes, although few studies have measured this outcome (Hoagwood, Olin, et al., 2007; Durlak, Weissberg, et al., 2007). A meta-analysis of programs that include academic achievement as an outcome concluded that

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85 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS the effects of social and emotional learning programs were equivalent to a 10 percent point gain in test performance (Durlak, Weissberg, et al., 2007). Students participating in the program also demonstrated improvements in school attendance, school discipline, and grades. Hoagwood, Olin, et al. (2007) found similar results in a review of school-based interventions that targeted psychological problems, with 15 of 24 studies showing benefits for both psychological functioning and academic performance. However, the academic effects were modest and often short-lived. Reviews of violence prevention initiatives support their efficacy in reducing violence and aggressive behavior (Centers for Disease Control and Prevention, 2007; Hahn, Fuqua-Whitley, et al., 2007). Based on a system- atic review and meta-analysis of 53 universal prevention interventions, the CDC Task Force on Community Preventive Services recommends the use of universal school-based programs for preventing violence and improving behaviors in school. The effects of the reviewed programs were generally greater among preschool and elementary school-age children (Centers for Disease Control and Prevention, 2007). A recent report by the surgeon general disputes the myth that nothing works with respect to treating or preventing violent behavior (U.S. Public Health Service, 2001c). The report identifies 7 model and 21 promising programs, primarily school-based, for preventing either violence or risk factors for violence.2 The Center for the Study and Prevention of Violence applies a rigorous set of criteria (experimental design, effect size, replication capacity, sustain- ability) to identify programs effective in reducing adolescent violent crime, aggression, violence, or substance abuse. The center has identified 11 model programs and 17 promising programs,3 several of which are highlighted in this and the next chapter. Most have demonstrated positive effects on multiple problem outcomes. Combined School and Family Interventions in Elementary School A number of interventions that combine multiple types of programs (e.g., parenting and schools) or multiple levels (e.g., universal and selective) are beginning to emerge, primarily in elementary schools. The Incredible Years Program (see Box 6-2) combines parent and school interventions and has been tested in both preschool and elementary settings. In some cases, integrated efforts have included a family or school-based 2 Seehttp://www.surgeongeneral.gov/library/youthviolence/toc.html. 3 Seehttp://www.colorado.edu/cspv/blueprints. Other recommended school-based programs not highlighted in these chapters listed on this site include the Olweus Bullying Prevention Program and the I Can Problem Solve Program.

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86 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 6-9 Fast Track: A Comprehensive, Long-Term, Multilevel Intervention for Students at High Risk of Antisocial Behavior Fast Track is a multisite randomized controlled trial of a comprehensive and extended intervention to prevent antisocial behavior (Conduct Problems Research Group, 1999a, 1999b). Schools in Washington State, North Carolina, Tennessee, and rural Pennsylvania were chosen to participate because they had high rates of crime and poverty in their neighborhoods. Schools at each site were matched on demographics and randomized to the intervention or a usual care control con- dition. Three successive cohorts of kindergarten students in these schools were screened for teacher-rated conduct problems. Those who scored among the top 40 percent were further screened using parent ratings of behavior problems. The standardized sum of these scores was used to select a sample of 446 control children and 445 intervention children who scored highest in conduct problems. The intervention continued through 10th grade. In the younger grades, it included parenting behavior management training, social and cognitive skills training for students, tutoring in reading, and home visiting. In 5th and 6th grades there was increased focus on monitoring and limit setting. In 7th and 8th grades, students received lessons on identity and vocational goal setting. During 7th and 10th grades, assessments occurred three times a year, and further individualized interventions were implemented with each youth, based on his or her behavior and needs. The children and their families were also exposed to the PATHS program (see Box 6-7). The Conduct Problems Research Group (2007) reports the effects of the intervention as of 9th grade, primary among which was less antisocial behavior for the intervention students. There were no main effects on the incidence of diagnoses of conduct disorder, oppositional defiant disorder, or attention deficit hyperactivity disorder (ADHD). Among the highest-risk youth who received the intervention, only 5 percent received a conduct disorder diagnosis, while 21 percent received it in the usual care condition (the rate was 4 percent in the normative sample). The rate of ADHD diagnosis was also significantly lower in the high-risk intervention sample than in the high-risk usual care sample. It is likely that providing this intervention only to high-risk children would have a favorable benefit-to-cost ratio. intervention that has already demonstrated positive effects separately. For example, the Linking Interests of Families and Teachers (LIFT) project incorporated behavioral parent skills training and a variant of the Good Behavior Game, with preventive effects sustained at three-year follow-up (Eddy, Reid, and Fetrow, 2000). The Fast Track project (see Box 6-9) incor- porates PATHS as one part of a comprehensive, long-term intervention with universal, selective, and indicated components. The long-term effects of Fast Track were most significant for the highest-risk participants.

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87 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS The Seattle Social Development project, a universal quasi-experimental intervention in the elementary grades, was designed to reduce risk and build protective strengths in schools, families, and children themselves. Long-term follow-up revealed multiple positive effects on mental health, functioning in school and work, and sexual health 15 years after the intervention ended (Hawkins, Kosterman, et al., 2005, 2008). COMMUNITY INTERVENTIONS Preventive interventions in communities generally have two features. First, they target the prevention of an outcome in an entire population in the community, such as tobacco use among adolescents. Community inter- vention research provides a target of manageable size for testing whether such population-wide effects can be achieved. Second, these interventions target multiple influences on the behavior of interest, often through multiple channels. Community interventions are attractive because they can encom- pass all major influences on a behavior. Most experimental evaluations of community interventions involve the prevention of adolescent use of tobacco, alcohol, or other drugs. These studies are discussed in the substance use section of Chapter 7, which focuses on disorder-specific prevention approaches. Flay, Graumlich, and colleagues (2004) evaluated one comprehensive community intervention and a social skills curriculum for preventing mul- tiple problems among early adolescents. A total of 12 poor predominantly African American schools in Chicago were randomly assigned to receive the social skills curriculum, a school/community intervention, or a health education control condition. The social skills curriculum was especially designed for African American young people. The school/community inter- vention added several elements to the social skills curriculum: (1) in-service training of school staff; (2) a local task force to develop policies, conduct schoolwide fairs, seek funds for the school, and conduct field trips for par- ents and children; and (3) parent training workshops. Both the social skills curriculum and the school/community intervention significantly reduced the rate of increase in violent behavior, provoking behavior, school delin- quency, drug use, and recent sexual intercourse and condom use among boys compared with the control condition. The school/community inter- ventions were significantly more effective than the social skills intervention on a combined behavioral measure. Girls, who generally had lower rates of problem behavior, were not affected by the program. A subsequent analysis showed that the effects were due to changes in the boys who were at high- est risk (Segawa, Ngwe, et al., 2005). Much remains to be learned about how to mount effective interven- tions in entire communities. The predominance of the single-problem focus

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88 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS on substance use in existing evaluations of community interventions high- lights a significant gap in the field given that community-wide interven- tions, including those that incorporate components targeting families and schools, have the potential to address a wider set of common risk factors comprehensively. Communities That Care, a system to help communities identify and prioritize risk factors and implement tested interventions that address those factors, is being tested in a randomized trial with positive initial results (see Box 11-1). The media and the Internet are emerging as means to reach local com- munities beyond schools and families, as well as the broader community, more widely. Their extensive use by today’s young people makes develop- ment and testing of evidence-based promotion and prevention interventions using these venues particularly attractive. For example, Triple P (see Box 6-3) has had some positive results in communicating information about parenting via the media. If effective media-based interventions were avail- able, they could be especially valuable in cases in which the local health care system has not allocated resources for preventive services, or the com- munity, school, workplace, or family unit has chosen not to participate in preventive programs. There are early indications that interventions pro- vided on CD-ROM can be effective at reducing risk of alcohol use, drug use, and violence (Schinke, Schwinn, et al., 2004; Schinke, Di Noia, and Galssman, 2004). A series of creative studies has demonstrated the wide reach and effec- tiveness of entertainment media approaches. One of the pioneers in this area is Miguel Sabido (Singhal, Cody, et al., 2003). Using social-cognitive techniques developed by Albert Bandura (2006), Sabido has documented significant impact of these approaches in Mexico on such practices as the utilization of national literacy resources and family planning. The latter was measured by documenting the use of contraceptives, which showed annual increases of 4 percent and 7 percent, respectively, in the two years preceding the airing of a television serial novel (telenovela) addressing family planning and 23 percent in the year the program was aired. Studies of the impact of electronic media (such as television, computer- assisted interventions, and websites) on other health-related behaviors have also found positive effects in such areas as cognitive-behavioral mood management skills (Muñoz, Glish, et al., 1982), mental health interven- tions (Marks, Cavanagh, and Gega, 2007; Barak, Hen, et al., 2008), and smoking cessation (Muñoz, Lenert, et al., 2006). The National Institute for Health and Clinical Excellence in the United Kingdom has approved two computerized cognitive-behavioral therapy interventions for depression and panic/phobia disorders (Christensen and Griffiths, 2002).4 The Psychosocial 4 See http://www.nice.org.uk/TA97.

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8 FAMILY, SCHOOL, AND COMMUNITY INTERVENTIONS Intervention Development Workgroup of the National Institute of Mental Health has recommended the development and testing of Internet-based preventive interventions focused on many disorders and many languages (Hollon, Muñoz, et al., 2002). The potential of media-based interventions for the prevention of MEB disorders warrants additional research. CONCLUDING COMMENTS Meta-analyses and numerous randomized controlled trials have dem- onstrated strong empirical support for interventions aimed at improving parenting and family functioning. Interventions focused on reducing aggres- sive behavior, avoiding substance use, reducing HIV risk, securing perma- nent foster care placement, and dealing with difficult family situations such as divorce have all produced beneficial effects. The interventions emphasize improving communication; promoting positive parenting techniques, such as parents’ supportive behaviors toward their children; reducing the use of harsh discipline practices; and increasing parental monitoring and limit setting. Many interventions have demonstrated effects on multiple problem behaviors, shown positive effects in both prevention and treatment con- texts, and produced lasting effects. Generic efforts to improve parenting skills in families with children and early adolescents could have benefits in preventing a range of problem behaviors, particularly externalizing behaviors. This possibility deserves more exploration through assessment of the impact of family interventions on the entire range of child and adolescent problems. Substantial development of empirically validated school-based pro- grams that can reduce risk for MEB disorders in young people has also occurred. Many of these interventions focus on promoting positive child behavior or preventing behavior problems, with some positive results tar- geting MEB disorders more specifically. Interventions are often designed to address risk and protective factors associated with violence, aggression, and substance use. Many tend to focus on skill development to improve students’ relationships, self-awareness, and decision-making skills. Some programs have also focused on school structural factors, teacher classroom management, or school–family relations. Universal, selected, and indicated interventions have been developed for both school and family settings, with some programs including multilevel interventions. Studies have shown differential results in terms of effective- ness with different risk groups. There are some indications that interven- tions provided on a CD-ROM can be effective at reducing risk of alcohol use, particularly with parent involvement (Schinke, Schwinn, et al., 2004). Some studies have demonstrated better results for higher-risk groups, while

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0 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS others have shown positive effects overall but reduced benefits for groups with multiple risk factors. Several interventions highlighted in this chapter have been tested in two or more randomized controlled trials and in evaluations by researchers other than the developers of the interventions. Evidence has been found for long-term results with different populations. Many other promising inter- ventions have not yet been subjected to this level of testing. Given the convergence of evidence related to the positive effects of interventions aimed at improving family functioning and family support, the committee concludes that this area warrants both concerted dissemi- nation and continued research. Some factors, such as poverty, that have notable effects on multiple disorders but have not been subjected to much empirical research merit rigorous evaluation. Similarly, the evidence of positive effects from school-based interven- tions points to the considerable potential—with the support of continued evaluation and implementation research in collaboration with educators—of prevention practices in schools aimed at increasing the resilience of children and reducing the risk for MEB disorders. Also promising are interventions at the level of communities, including local community interventions, as well as mass media and Internet interventions, and approaches targeting policies, which warrant continued and rigorous research.