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12 Prevention Infrastructure T he development and ultimate success of efforts to improve mental, emotional, and behavioral outcomes among young people depend heavily on the availability of systems to support efforts in three domains: research and innovation, training, and delivery of successful inter- ventions. This chapter addresses three key interconnected topics: (1) funding for research, training, and service delivery programs; (2) the adequacy of access to prevention delivery systems; and (3) content of training programs directed to enhancing the prevention workforce. The chapter begins with a discussion of federal funding, highlighting the challenges in determining the level of funding for either prevention research or services, indications that the federal commitment to preven- tion research may have waned since the publication of Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (Institute of Medicine, 1994), and the lack of systematic coordination of either research or service delivery efforts. It then moves to issues related to the development of prevention delivery systems, including discussion of mul- tiple federal efforts related to prevention and promotion, the need for consistent, rigorous standards to identify effective interventions, and illus- tration of some existing state and local efforts to develop delivery systems. The chapter closes with discussion of gaps in prevention-specific training in a range of disciplines, pointing out that prevention efforts are likely to continue to languish without targeted attention to preparing the future prevention workforce. 7

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8 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS FUNDING It is difficult to quantify current funding for either prevention research or prevention services, due to the many agencies involved, varied defini- tions and tracking systems used by agencies, and the multiple levels of service funding and delivery. In some cases, prevention is a piece of a larger program or an eligible activity under a block grant, but there is no specific accounting of the proportion targeted to prevention. Similarly, programs that fund services aimed at addressing factors that contribute to preven- tion of mental, emotional, and behavioral (MEB) disorders clearly have an important role to play in prevention, but they cannot fairly be claimed as prevention programs in their entirety—for example, child abuse prevention programs. In addition, there is no national network or organization that coordinates all preventive efforts, either for research or services, from which funding estimates can be generated. While more states and counties have been investing in prevention activities, the scope of that investment has not been monitored systematically. Research Funding Multiple components of the U.S. Department of Health and Human Services (HHS), including the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), the Maternal and Child Health Bureau (MCHB), the Centers for Disease Control and Pre- vention (CDC), and the Administration for Children and Families (ACF) fund prevention research involving young people. The research arms of the U.S. Department of Education (ED) and the U.S. Department of Justice and private foundations also fund relevant research. Published randomized controlled trials (see Figure 1-1) tend to be funded primarily by HHS. Of those with an identified funding source,1 almost three-quarters (74 percent) received some funding from HHS; more than half (57 percent) received all of their funding from HHS. Given that NIH is the largest source of research funding in HHS, particularly for randomized controlled trials, it is reasonable to assume that they are the primary source of this funding. Only one in four published randomized controlled trials received all of its funding from a non-U.S. government source, such as foundations or foreign governments. 1 Funding information was available for 261 of the 424 (62 percent) published randomized controlled trials identified. The Public Health Service, which includes NIH and all of the health agencies within HHS, was the primary source.

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 PREVENTION INFRASTRUCTURE National Institutes of Health NIH publishes online their estimates of funding for various diseases, conditions, and research areas. Although the amount spent on “prevention” declined overall from $7.185 billion in fiscal year (FY) 2004 to $6.739 bil- lion in FY 2009, this includes all NIH institutes, so it is impossible to say to what extent this applies to prevention of MEB disorders among young people (see http://www.nih.gov/news/fundingresearchareas.htm). Determin- ing federal research funding for prevention in this area is also complicated by the current system for categorizing and reporting grants, which lacks a common definition of prevention. This situation exists despite a definition of prevention accepted by the NIH Prevention Research Coordinating Com- mittee,2 updated in 2007. NIH is nearing the end of a project to establish an NIH-wide system for coding funded projects, the Research, Condition, and Disease Catego- rization (RCDC) system.3 This system has been developed in response to a requirement that was added to the NIH Reauthorization Act in 2006. It will be able to produce a complete annual list of all NIH-funded projects related to each of 360 categories, including prevention, using standard defi- nitions that will be used across all NIH centers and institutes. Projects will be coded for all applicable categories to allow for funding information to be searched and cross-referenced by multiple categories. The first funding report is expected to be available on a public website in spring 2009 for project funding in FY 2008, and it will not be applied retroactively to pre- vious years. Once in place, this new system should improve the availability of consistent, accurate information on NIH funding for the prevention of MEB disorders. It is unclear, however, how prevention will be defined for the RCDC system. Furthermore, there are no plans for the RCDC system to provide link- age to financial data, limiting opportunities to quantify the federal invest- ment in prevention research. NIMH, NIDA, and NIAAA Funding The National Institute of Mental Health (NIMH), the National Insti- tute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) are the NIH institutes with direct responsibility for research related to prevention of MEB disorders, and they are a signifi- cant source of funding for intervention research. The National Institute of Child Health and Human Development (NICHD) also plays a critical role 2 See http://odp.od.nih.gov/research.aspx. 3 See http://rcdc.nih.gov/.

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40 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS in exploring developmental pathways and healthy development of young people. The committee requested historical data on prevention and treat- ment research and narrative information on FY 2006 funding from NIMH, NIDA, and NIAAA. However, these institutes were not able to provide uniform data and, with the exception of NIMH, were not able to provide longitudinal data. None routinely tracks its prevention research projects as universal, selective, or indicated. NIMH was able to provide the most comprehensive financial data. Although both prevention and treatment intervention research funding increased between 1999 and 2006, prevention intervention research fund- ing represented a smaller proportion of the overall NIMH budget than treatment intervention research (6.62 percent versus 8.75 percent, respec- tively, in FY 2006). If research aimed at “prevention of negative sequelae of clinical episodes, such as comorbidity, disability, and relapse or recur- rence” were classified as treatment intervention research, consistent with the committee’s definitions of prevention and treatment (see Chapter 3), the discrepancy between funding for prevention (6.72 percent in 2006) and treatment intervention research (14 percent in 2006) would be considerably greater (see Figure 12-1). In addition, both the percentage increase between 1999 and 2006 (80 and 102 percent for prevention and treatment interven- tion research, respectively) and the total funding ($94.4 and $122.8 million, respectively, in FY 2006) were much less for prevention than for treatment intervention research. Consistent with the 1994 Institute of Medicine (IOM) report Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research funding for prevention research4 on drug abuse was proportionately greater than the funding for prevention research on mental disorders. Between 1999 and 2006, the proportion of NIDA’s total appropriation expended for prevention ranged from 13.4 to 14.5 percent, while that of NIMH ranged from 5.7 to 7.6 percent during the same time period. The vast majority of NIAAA prevention research in FY 2007, the only year for which estimates were provided, focused on underage drinking. Organizational Structure. When the 1994 IOM report was published, NIMH, NIDA, and NIAAA each had a prevention research branch; only NIDA has one today. The NIDA prevention research branch remains in the Division of Epidemiology, Services, and Prevention Research (previously called the Division of Epidemiology and Prevention Research). NIAAA now has a Division of Epidemiology and Prevention Research, which works collaboratively with other divisions. NIMH has established an associate director position in the Office of the Director with coordinating respon- 4 NIDA was not able to provide an accounting of treatment research.

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4 PREVENTION INFRASTRUCTURE 18 16 14 12 Percentage 10 8 6 4 2 0 1999 2000 2001 2002 2003 2004 2005 2006 Year Preventive intervention research Prevention of negative sequelae of clinical episodes, such as comorbidity, disability, and relapse or recurrence Treatment intervention research (maintenance treatment or acute cure) Treatment intervention research using committee’s definition FIGURE 12-1 Proportion of NIMH budget for prevention and treatment in inter- vention research. SOURCE: Committee analysis of data provided by NIMH. Fig12-1.eps sibilities related to prevention. The position, however, has no funding authority. NIMH does have a Child and Adolescent Treatment and Pre- ventive Intervention Research Branch, which funds many of its prevention research projects; HIV prevention programs are funded out of its Primary Prevention Branch. Research Centers. NIMH, NIDA, and NIAAA also fund university-based prevention research centers5 (see Table 12-1). The centers conduct training and research related to a range of prevention-related issues, largely focused on young people. The number of NIMH-funded centers decreased from five 5 NIMH and NIDA each also fund a center that addresses prevention methodology (see Chapter 9).

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42 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS TABLE 12-1 Prevention Research Centers NIDA Transdisciplinary Prevention NIMH Research Centers (TPRCs) NIAAA Prevention Research Center Duke University TPRC: Prevention Research for Families in Stress, Center, Pacific Institute for Focused on the role of peer Arizona State University: Research and Evaluation: networks in prevention Focused on interventions research. Focused on basic and with children at risk for applied research leading to Drug Abuse Prevention During developing mental health the development of Developmental Transitions, problems because of effective prevention Rutgers University: Focused on exposure to high-stress programs to reduce situations, such as parental how individuals transitioning alcohol abuse and related divorce or death. developmental phases acquire problems, with an and integrate information emphasis on environmental Center for Prevention and about substance use into their approaches. Early Intervention, Johns behavior and how that Hopkins University Youth Alcohol Prevention knowledge can be applied to Collaboration: A Center, Boston University the design of preventive School of Public Health: collaborative focused on interventions. interventions to reduce Focused on alcohol-related Pathways Home: Reducing aggressive/disruptive problems among young Risk in the Child Welfare behavior in children people. System, Oregon Social through elementary school- Learning Center: Focused on based interventions. developing effective and Prevention Programs for feasible parenting interventions Rural African American for children and their families Families, University of in the child welfare system. Georgia: Focused on the USC Transdisciplinary Drug implementation of Abuse PRC, University of interventions with rural Southern California: Focused African American families. on the application of research on memory, implicit cognition, and network analysis theory to the design of prevention interventions. Drug Abuse Prevention: A Life Course Perspective, University of Kentucky: Focused on the role of novelty/sensation- seeking behavior in the onset and trajectory of drug abuse and applying this information in the tailoring of prevention efforts. NOTES: NIAAA = National Institute on Alcohol Abuse and Alcoholism, NIDA = National Institute on Drug Abuse, NIMH = National Institute of Mental Health.

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4 PREVENTION INFRASTRUCTURE to three between FY 1993 (the last year included in the 1994 IOM report) and FY 2006. NIDA currently funds five Transdisciplinary Prevention Research Centers (TPRCs) designed to bring together the expertise of basic and applied disciplines to accelerate the development and implementation of preventive interventions. Neuroscientists, behavioral and cognitive scien- tists, and drug abuse prevention researchers collaborate on discovery and translational research areas that have the potential for producing new approaches to drug abuse prevention. Similar mechanisms do not currently exist in NIMH or NIAAA or across the three institutes. NIAAA funds two prevention centers: the long-standing Prevention Research Center based at the University of California, Berkeley, and a new center focused on youth alcohol prevention. Intervention Research Portfolio Snapshot. The FY 2006 abstracts for projects focused on young people (ages 0-25)6 provide a one-year snapshot of NIMH, NIDA, and NIAAA prevention intervention research funding. Abstracts were coded by two reviewers on a variety of categories, including intervention type (universal, selective, indicated), trial type (efficacy, effec- tiveness, implementation), targeted risk factors, outcomes, and mediators; targeted population; and the location and provider of the intervention.7 The coding results were analyzed for 35 NIMH abstracts, 77 NIDA abstracts, and 53 NIAAA abstracts. We conclude from this analysis (see Box 12-1) that there is an emer- gence of effectiveness trials, but a lack of research that experimentally evaluates factors influencing implementation and dissemination of interven- tions. Appendix F provides a detailed summary of the analysis results.8 The analysis argues for greater attention to economic analyses as well as evalu- ations that assess multiple outcomes. The current research portfolio does not address gaps identified by the committee, including the need to expand research to cover more settings that provide opportunities to prevent MEB 6 At the time the information was submitted by NIMH and NIDA, FY 2006 was the most recent year for which complete data were available. NIAAA, which submitted information later, provided data for FY 2007. NIMH grants provided to the committee included those that are coded in their database as targeting ages 0-25. It did not provide grants coded as “age unspecified,” which may include some grants funded by NIMH that target this population. 7 Abstracts classified by NIMH as prevention of negative sequelae were included, but only projects considered by the committee to be prevention were included in this analysis. The cod- ing was refined through a pilot phase involving multiple reviewers, with final coding conducted by two independent reviewers. Where the two reviewers did not agree on a code, a consensus was reached in consultation with a third coder. This was needed most often for the interven- tion type (24 percent of the abstracts) and trial type (38 percent of the abstracts). 8 This appendix is available online only. Go to http://www.nap.edu and search for Preventing Mental, Emotional, and Behavioral Disorders Among Young People.

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44 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS BOX 12-1 Prevention Intervention Research at NIMH, NIDA, and NIAAA, Fiscal Year 2006 Intervention Type and Trial Type • NIDA and NIAAA funded a greater proportion of universal intervention trials than NIMH. • NIMH funded the largest proportion of efficacy trials (51 percent); NIDA grants were more evenly divided between efficacy and effectiveness; and NIAAA funded the largest proportion of effectiveness trials (53 percent). • Overall, there were relatively few implementation or dissemination projects (4-18 percent), although these were most common for NIDA. Most included an experimental comparison of different strategies. • A very small number of grants (6-11 percent) included any mention of eco- nomic analysis of the intervention. • Close to half of the projects across institutes mentioned long-term follow-up (more than one year) as part of their protocol. Outcomes, Risk Factors, and Mediators • HIV/AIDS (27 percent) and risky sexual behavior (29 percent) were the most common target outcomes for NIMH grants. These were followed closely by depression (25 percent), conduct problems (20 percent), academic perfor- mance (18 percent), and anxiety (16 percent). • HIV/AIDS and risky sexual behavior were also frequently targeted by NIDA and NIAAA. About one-quarter of NIDA projects also targeted academic per- formance, conduct problems, and other mental health issues. • The majority of NIMH grants focused on measuring single outcomes, with only a third of the grants targeting multiple outcomes. Grants funded by NIDA and NIAAA were more likely to address multiple outcomes. • Projects targeted primarily individual-level risk factors, and over three-quarters of grants for all three agencies target the child as the mediator; that is, the project aimed to change the skills or beliefs of the targeted group of young people. disorders, greater attention to cultural appropriateness and adaptation, and interventions for young adults. Centers for Disease Control and Prevention CDC has an active public health research portfolio that includes a focus on child development. In its 2006 publication Advancing the Nation’s Health: Guide to Public Health Research, 2006-205, health promotion is

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45 PREVENTION INFRASTRUCTURE • The family was more likely to be a targeted mediator in NIDA-funded projects. • NIAAA was the only agency in which policy was identified as a mediator (9 percent). Population, Location, and Provider • The majority of grants in all three agencies targeted school-age children, adolescents, or young adults, with fewer than 10 percent focusing on early childhood. • Around one-quarter of both NIDA and NIMH abstracts focused on children of elementary school age, with the remainder focused primarily on middle school and high school. • Young adults were an infrequent target of intervention by both NIMH and NIDA projects. NIAAA had both substantially more projects targeting young adults (68 percent) and a large proportion of projects in colleges (47 percent), due to their specific research portfolio focusing on interventions targeted at 21- to 25-year-olds. • Although a significant number of NIMH and NIDA grants take place in school settings, relatively few have school personnel (rather than research staff) as the provider of the intervention. • Very few trials take place in the health care system or in other government agencies that serve children and families, and very few projects indicated that they were evaluating cultural adaptations of existing interventions. NOTES: NIAAA = National Institute on Alcohol Abuse and Alcoholism, NIDA = National Institute on Drug Abuse, NIMH = National Institute of Mental Health. SOURCE: Based on analysis of 35 NIMH, 77 NIDA, and 53 NIAAA project abstracts. one of six specified areas, although the role of mental health promotion is unclear. In the area of health promotion, creating healthy schools is one of the target areas. In addition, CDC provides funding for Community-Based Participatory Prevention Research, although prevention of MEB disorders among young people has been a relatively small component of funded projects.

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46 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Private Foundations Currently, apart from religious congregations, total annual charitable expenditures in the United States are about $1 trillion. Depending on fund- ing priorities, the amount of this investment should grow substantially, possibly more than double, as an unprecedented intergenerational transfer of wealth is predicted to occur between 1998 and 2052 (Fleishman, 2007). This will provide an opportunity to increase research for prevention of MEB disorders, especially if foundation boards are educated about the social and economic costs of mental disorders at a time when the United States needs a strong and productive workforce. Some private foundations already support preventive services and research related to mental, emo- tional, and behavioral problems among young people. Information on the amount of this investment is unavailable, but it is likely to be modest.9 Preventive Services Funding There are no current estimates of overall national spending on preven- tive services. The most recent estimate concluded that in 1995 federal agen- cies contributed $1.8 billion, state Medicaid contributed $1.3 billion, and employee assistance/wellness programs contributed $1.2 billion toward the prevention of mental illness (Harwood, Ameen, et al., 2000). This would translate to $5.9 billion in 2007 dollars. Federal Investments Similar to the situation at the time of the 1994 IOM report, multiple federal agencies fund programs and services related to the prevention of MEB disorders. Although few are directly targeted to this task, there are many more federal efforts to encourage prevention and promotion activities than was the case in 1994, particularly activities targeted to mental health activities in schools. The lead federal agency and largest funder of prevention of mental health disorders and substance abuse is the Substance Abuse and Mental Health Services Administration (SAMHSA). Within SAMHSA, this falls to the Center for Substance Abuse Prevention (CSAP) and the Center for Mental Health Services (CMHS), primarily through its Division of Preven- tion, Traumatic Stress and Special Programs. Unlike CSAP, which has the 9 The Child Mental Health Foundations and Agencies Network, a group of public and private agencies and foundations interested in issues of child development and public policy, aims to improve connections between research, practice, and policy. A request was submit- ted to its members for information on relevant activities, but none was received in time for consideration in this report.

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47 PREVENTION INFRASTRUCTURE Center for Substance Abuse Treatment as a sister agency, CMHS must address both treatment and prevention issues. Other major federal funding sources include the Office of National Drug Control Policy, MCHB, ED (including such initiatives as Safe and Drug-Free Schools10), and the Office of Juvenile Justice and Delinquency Prevention. ACF is the primary funder of Head Start and child welfare programs, and CDC is involved in suicide prevention programs and surveillance efforts. In 2004, SAMHSA awarded $230 million over 5 years to 21 states for the creation of Strategic Prevention Frameworks (Substance Abuse and Mental Health Services Administration, 2004), an approach to planning and implementing prevention programs, broadly based on principles drawn from research. These funds are helping states to build the infrastructure and processes needed to promote healthy youth development, reduce risky behaviors, and prevent problem behaviors through community programs. Although there are block grants for both mental health (Mental Health Services Block Grant) and substance abuse (Substance Abuse Prevention and Treatment Block Grant), only the substance abuse block grant includes a set-aside for prevention. States are mandated to use 20 percent of their block grant resources for universal, selective, and indicated prevention activities. In FY 2001, SAMHSA/CMHS awarded targeted capacity expan- sion grants for prevention and early intervention services, but the program has not been continued. In 2006, Safe and Drug-Free Schools at ED appropriated $510 million for numerous programs targeting prevention of mental disorders and sub- stance abuse. These programs focus on preventing illegal drug and alcohol use among youth and creating violence-free educational environments for both school- and college-age youth. Grants for the integration of Schools and Mental Health Systems aim to increase linkages between schools, men- tal health, and juvenile justice authorities to improve access to quality men- tal health services, including preventive services. ED also provides grants to assist local education authorities develop “innovative and effective” alcohol abuse prevention programs. Increased concern about violence also led to the creation in 1999 of the Safe Schools/Healthy Students (SSHS) Program, a collaboration of HHS, ED, and Justice. Through this program, local education agencies receive three-year grants to work in partnership with local law enforcement and mental health agencies to develop a comprehensive approach to violence prevention that 10 The Office of Safe and Drug-Free Schools administers several programs with preventive goals, including the Healthy Student Initiative, Governors’ Grants, Grants to States to Improve Management of Drug and Violence Prevention Programs, State Grants, Prevention Models on College Campuses, Grants for School-based Student Drug Testing, Grants to Reduce Alcohol Abuse, and Grants to Prevent High-risk Drinking and Violent Behavior Among College Stu- dents (U.S. Department of Education).

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66 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS in pediatrics are not formally trained to recognize chronic health disorders as risk factors for MEB disorders of youth. Requirements for training in preventive medicine25 are largely • silent with regard to prevention of MEB disorders. Core knowl- edge is expected to include “behavioral aspects of health,” but the requirements do not otherwise address MEB disorders or their pre- vention. The certifying examination for preventive medicine does not specifically test knowledge or skills directed to prevention of MEB disorders. Drug use training in preventive medicine residency largely focuses on tobacco (Abrams, Saitz, and Sancet, 2003). None of the medical specialty training requirements emphasize the need to be conversant with screening for risk or protective factors for mental dis- orders or to understand systems that are in place to manage risk as well as reinforce protective factors. The overall lack of attention to training related to prevention of MEB disorders contrasts with a consensus in the pediatric community that training for residents should be enhanced to prepare them for more knowledgeable, competent behavioral/mental health screening and care (American Academy of Pediatrics, 2001; American Academy of Pediatrics Task Force on Mental Health, in preparation). The American Board of Family Medicine (ABFM) has identified similar needs for their trainees (personal communication with Larry Green, ABFM board member, October 8, 2007). Social Work Master’s-level social work training (the routine degree for practi- tioners) currently is provided by approximately 200 programs accredited by the Council on Social Work Education. Accreditation standards do not address substance use in general or prevention in this realm (Straussner and Senreich, 2002). Curriculum requirements emphasize content in human behavior, clinical diagnosis, treatment planning, and service delivery. Pre- vention frameworks and program examples are included in the Human Behavior and Social Environment course sequences required of all social work graduate curricula. While a 1996 report (Perry, Albee, et al., 1996) found that only 12 schools offered a course in prevention (not specifically prevention of MEB disorders), most schools of social work have elective courses in drug and alcohol abuse prevention, and many offer courses in mental health interventions, as well as child maltreatment prevention and treatment. 25 Preventivemedicine is a three-year training program for physicians that combines a year of clinical medicine and 24 months of academic and practicum training, leading to an M.P.H.

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67 PREVENTION INFRASTRUCTURE Since 1993, NIMH has funded a small number of social work programs to conduct research as well as provide special scholarships and coursework on prevention research for doctoral students, which has increased the sup- ply of researchers trained in prevention research methods (Institute for the Advancement of Social Work Research, n.d.). Recently, NIMH launched other initiatives to enhance partnerships to integrate evidence-based mental health practices into social work education and research (Institute for the Advancement of Social Work Research, n.d.), but prevention research is a relatively small part of these initiatives. Clinical Psychology. There are approximately 90,000 clinically trained psychologists in the United States, many of whom have training in child psychology. Training in prevention of MEB disorders is not standard for most master’s- or doctoral-level curricula or for certification or licensure in school psychology. A 2003 report of a task force of the Society of Pediatric Psychology recommended 12 topic areas most important for training expe- riences of child psychologists. Three of these areas were prevention, family support, and health promotion (Spirito, Brown, et al., 2003). Similarly, in their call for redesign of clinical psychology graduate education, Snyder and Elliott make a case for focus on individual strengths (protective factors), and lifestyle or community-level influences on mental health. They con- clude that prevention must be an essential feature of education curricula. They note that a few psychology training programs do stress reduction of risk factors, but they recommend that postdoctoral programs in clini- cal psychology increase their focus on prevention and health (Snyder and Elliott, 2005). The response to these recommendations will be important to monitor. Similarly, psychologists typically receive little training or prepara- tion for dealing with substance abuse. Half or more receive no didactic or practical training in substance use conditions according to a 1990s survey (Institute of Medicine, 2006b). Their clinical training, as for other health professionals, is focused on diagnosis and treatment. Certification of clinical competence is offered by the American Board of Professional Psychology. Licensure in some states requires written or oral evaluations of knowledge. Neither licensure nor certification assesses competence related to prevention of MEB disorders. Community psychology, developmental psychology, and social psychology are other potential training pathways for a career in preven- tion research and program implementation, although none of these areas focuses exclusively or in major part on prevention. It is not uncommon for graduate students who wish to work in the area of prevention of MEB disorders to construct independent study programs (Perry, Albee, et al., 1996).

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68 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Nursing. Nursing education is generally completed in two (associate’s degree) or four years (bachelor’s degree; eligibility for licensure as a regis- tered nurse). Increasing numbers of nursing students become nurse prac- titioners with advanced degrees, either a master’s or a doctor of nursing practice. A number of nursing students are obtaining Ph.D.s, acquiring nursing research skills, and working in academic or research settings. Nursing school curricula stress prevention concepts, but most devote little time to prevention of MEB disorders. One effort has been the Nursing Child Assessment Satellite Training at the University of Washington, a national program to train nurses and other health care professionals to assess parent–child relationships in community settings.26 Psychiatric nurses (more than 18,000; Institute of Medicine, 2006b) usually have added train- ing or a graduate degree and are certified by the American Nurses Creden- tialing Center. There are more than 20 university-based master’s degree programs in psychiatric nursing, many having specialty tracks specific to child and adolescent psychiatric nursing, and a certification process for child/adolescent psychiatric nursing. As with other health care professions, advanced training does not uniformly target prevention. However, there are innovative efforts, such as a 2008 HRSA award to the College of Nursing at Arizona State University for the multidisciplinary online training pro- gram called KySS (Keep Your Child/Yourself Safe, and Secure), focused on screening, identifying, and delivering evidence-based intervention for youth experiencing common MEB problems.27 Prevention training related to MEB disorders in nursing is an important opportunity. Substance Abuse and Mental Health Counseling. Substance abuse counselors and mental health counselors together comprise the largest group of mental health professionals. Numbers of mental health counselors alone approach 120,000, and half of the personnel delivering substance use treatment are substance abuse counselors (Institute of Medicine, 2006b). Coursework and practical experience requirements vary between these two groups, across state lines, and from program to program. Licensure or certification is required by some states, more for mental health than for substance abuse counselors. Requirements for coursework or practicum experience, when they are specified, do not include exposure or experience related to preven- tive aspects of MEB disorders (Kerwin, Walker-Smith, and Kirby, 2006). The content of continuing education is largely unspecified and does not require that preventive aspects of MEB disorders be addressed. While many states have certified preventionist positions in the area of substance abuse 26 See http://www.ncast.org/index.html. 27 See http://www.napnap.org/index.cfm?page=198&sec=221&ssec=499.

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6 PREVENTION INFRASTRUCTURE prevention, with criteria for certification specified, no comparable position exists in the mental health area. Education Providers Neither the core curriculum for a bachelor’s degree nor the process for obtaining a teaching certificate anticipate that teachers will be prepared to recognize risk factors or detect early evidence of MEB disorders in their pupils. Coursework for education degree students includes descriptions of mental disorders (along with physical disorders and retardation), but it does not systematically include how to identify, intervene, or refer children at risk for MEB disorders. Special education trains teachers to recognize and work with children who have special needs that schools, by law, must address. Children with externalizing disorders (conduct, hyperactivity) are identified and directed to remedial programs when they are disruptive. Children with internalizing disorders (e.g., withdrawal, anxiety, depres- sion) are often not identified for attention because they do not impose an added burden on the teacher or classroom. As federal mandates for testing and academic achievement have been strengthened, MEB issues have been relegated to lower priority status for teachers. Training in evidence-based behavior management techniques for teachers is essential for helping them to address the behavior problems that can develop into MEB disorders (Epstein, Atkins, et al., 2008). The National Association of School Psychologists has 25,000 mem- bers and strongly encourages mental health promotion and prevention of disorders through a variety of programs. For example, Prevention, Crisis Intervention and Mental Health is 1 of 11 domains of the organization’s continuing professional development program (NASP Professional Devel- opment; see http://www.nasponline.org, accessed September 29, 2008). However, the contribution of school psychologists has limitations as a result of school budget contractions. Except for a few schools that have adopted specific experimental or innovative universal or selective interventions, most schools do not prepare their staff to screen for risk factors, nor do they adopt universal measures to decrease risk or enhance protective factors (personal communication, Mary Boat, College of Education, University of Cincinnati). In many ways, this is an opportunity lost, but transformational changes will be needed in school systems to respond to this opportunity. Nevertheless, the school setting represents one of the best opportunities for prevention interventions, whether universal, selective, or indicated. Preschools and day care centers (for children from birth to age 5) may be in the most advantageous position to observe young children and identify risks or early symptoms. However, preschool teachers often have less training than school teachers and are frequently unprepared to engage

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70 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS in activities that lead to identification and helpful intervention for mental, emotional, and behavioral problems. Law and the Judicial System While some individuals in the legal system appear to be aware and responsive to the needs of children, particularly those at risk for MEB dis- orders, children’s needs are often secondary to other considerations. Such situations arise frequently when such issues as child custody and visita- tion are decided in cases of divorce, domestic violence, or child abuse and neglect. Recognition that these situations place children’s mental health at risk should lead to decisions that consider, above all, the children’s well-being. Enhanced mechanisms for informing lawyers, magistrates, and judges about the role they can play in the prevention of MEB disorders should be adopted, starting in law school. Public Awareness and Public Policy A pivotal effort must target the training of youth, their families, and the public to understand the importance of mitigating risks for MEB disorders. This universal approach should include policy makers and individuals who determine how public and private funds will be allocated in the attempt to improve mental health outcomes for children. A public that is aware of the huge burden of MEB disorders, as well as the needs and opportunities for prevention, will be more likely to promote informed decision making about programmatic responses from both the private and the public sectors. Vehicles for dissemination of information include, first and foremost, the media, including opportunities to dispel the stigma associated with MEB disorders (see Chapter 8). Schools should also play a role, as should primary health care providers. Professional societies, as well as private and government agencies, should have major educational roles. Priorities have targeted diagnosis, treatment, and rehabilitation, per- haps at the expense of prevention efforts. Achieving the proper balance in the future will require informed discussions and decisions at the highest levels. Prevention often is not addressed because the public expects immedi- ate return on its investment. Education should include compelling informa- tion about the real and potential benefits and cost reductions of successful prevention efforts. In particular, this information should be directed to public policy makers. Education and possibly publicly supported incentives must also target health care payers who currently often refuse reimburse- ment for prevention efforts.

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7 PREVENTION INFRASTRUCTURE CONCLUSIONS AND RECOMMENDATIONS For the goals of prevention of MEB disorders to be achieved, the three elements of prevention program infrastructure in this chapter must be the focus of ongoing improvement efforts: innovation driven by funded research, a coordinated and effective delivery system, and enhancement of workforce quality and quantity. Developing a Coordinated and Effective Delivery System Numerous federal programs and resources fund and guide states and communities in their promotion and prevention efforts. Coordination across these efforts is limited and presents a barrier to large-scale imple- mentation of best practices. Funding for programs and their evaluation is fragmented and inadequate to reach many youth in need. As communities increasingly are able to select programs from available lists of evidence- based approaches, the infrastructure to sort out how best to match program features with community needs and resources and to learn what constitutes the most effective match is often not in place. Conclusion: Federal programs whose goals include the prevention of MEB disorders are not well coordinated, and there is little strategic synergy between research and service delivery. Compounding the deficiencies of infrastructure are substantial barriers to implementation of prevention programs in potentially advantageous settings, such as day care, schools, and primary medical care. Too often programs are created de novo and require costly new infrastructure. Bar- riers such as funding or reimbursement of services can be addressed most effectively at a national or state level. Program funding often does not include expectations that demonstrably effective programs be implemented with fidelity or that outcomes of these programs be rigorously evaluated, and it does not typically support outcomes assessments. Conclusion: There is a need for the development of systems (service sites and networks) that can implement evidence-based programs, test their effectiveness in real-world environments, and provide a funding stream for evidence-based prevention services. Funding and infrastructure for substance abuse prevention interven- tions is more advanced than for prevention or promotion of mental health. There are no targeted funding streams for prevention in the mental health area.

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72 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Recommendation 12-1: Congress should establish a set-aside for pre- vention 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. Providing a set-aside with the Mental Health Services Block Grant could send a clear message that prevention is a priority and begin to help refocus the mental health system on prevention activities. This should be the first step in refocusing the mental health system to include a targeted focus on prevention and should be coupled with efforts across agencies to increase prevention funding, including collaborations between SAMHSA and the Centers for Medicaid and Medicare Services to address barriers to reimbursement of prevention services. At the same time, innovation in other service systems is also needed, ideally coupled with rigorous evaluation to continue to develop prevention systems. Resources for preventive services, however, often do not include sufficient evaluation resources. Recommendation 12-2: 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 Sci- ences, the National Institute of Justice). This should include developing appropriate infrastructure through which evidence-based programs and practices can be delivered. Models for implementing braided funding, which is supported by NIMH’s Bridging Science and Services report (National Institute of Men- tal Health, 2006), could include joint requests for proposals or target- ing research resources to existing service programs. One example of the latter approach is a recent request for applications from NIH that targeted research resources for research activities tied to grantees under SAMHSA’s Comprehensive Community Mental Health Services Program for Chil- dren and Families.28 Other federal programs, such as initiatives under SAMHSA’s Strategic Prevention Framework, including the SSHS Program, could be similarly linked with NIH research resources. Numerous preventive interventions are now available and being implemented by states and communities. However, efforts to expand these 28 See http://grants.nih.gov/grants/guide/pa-files/PA-07-091.html.

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7 PREVENTION INFRASTRUCTURE interventions state-, county-, or locality-wide are needed to establish an infrastructure for the delivery of preventive interventions across systems of care. Recommendation 12-3: 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. A dizzying array of technical assistance centers, online resources, and publications and guides is available. Prominent among them are efforts to identify effective programs. Differences across these efforts, particularly in the standards applied, make it difficult to understand the meaning of an assigned rating or to assess the expected results of a given program. Recommendation 12-4: 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. In applying scientific criteria, the agencies should consider the following standards: • Evidence for efficacy or effectiveness of prevention and promotion programs should be based on designs that provide significant con- fidence in the results. The highest level of confidence is provided by multiple, well-conducted randomized experimental trials, and their combined inferences should be used in most cases. Single trials that randomize individuals, places (e.g., schools), or time (e.g., wait-list or some time-series designs) can all contribute to this type of strong evidence for examining intervention impact. • When evaluations with such experimental designs are not avail- able, evidence for efficacy or effectiveness cannot be considered definitive, even if based on the next strongest designs, including those with at least one matched comparison. Designs that have no control group (e.g., pre-post comparisons) are even weaker. • Programs that have widespread community support as meeting community needs should be subject to experimental evaluations before being considered evidence-based.

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74 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS • Priority should be given to programs with evidence of effectiveness in real-world environments, reasonable cost, and manuals or other materials available to guide implementation with a high level of fidelity. Also key to these efforts will be education of the public about the need for prevention efforts and the benefits that can be achieved. An informed and supportive public is needed to adopt and advocate for effective preven- tion of MEB disorders and promotion of better mental health outcomes. Research Although the volume of prevention research and evidence for suc- cessful intervention efforts has grown substantially since 1994, there are rapidly expanding needs for more and better research. In contrast to the need and opportunity, funding for studies of preventive interventions for MEB disorders and their implementation has taken a back seat to funding of studies directed to the diagnosis and treatment of behavioral disorders. In addition, no single agency (federal or private) has prioritized research funding directed to the prevention of MEB disorders or is driving preven- tion research efforts in a coordinated way. Conclusion: Federal agencies responsible for funding mental health research have prioritized studies of treatment over prevention. Several NIH institutes (NIMH, NICHD, NIDA, NIAAA, AHRQ) con- tribute substantially but focus largely on a single disorder. Coordinated funding by NIH institutes and other agencies is not visible. This paucity of prospective, collaborative funding makes it particularly difficult to generate an integrated, comprehensive approach to innovative prevention research. Funding mechanisms for stimulating research at the intersection of basic science and the development and implementation of new and better preven- tive interventions are needed now and will be increasingly critical in the future. Basic research in neurobiology, psychology, sociology, economics, and related fields should be supported to fuel the creation of novel strategies for prevention and to promote collaborative, multidisciplinary translational research to document the effectiveness of these strategies (see also Recom- mendations 5-2 and 5-3). Recommendation 12-5: 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

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75 PREVENTION INFRASTRUCTURE 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 the justice system). To date there is relatively little cofunding of prevention research across NIH institutes. Such efforts may be discouraged if each institute is not given sufficient recognition of its support on a cofunded grant. Given the importance of looking at comprehensive outcomes that are the purview of specific institutes and the current fiscal limitations for NIH research, it may be necessary to offer additional incentives for institutes to cofund impor- tant prevention research. The new policy at NIH that acknowledges the important contributions of multiple investigators is a model that could also be used at the institute level to acknowledge the contributions of multiple agencies providing cofunding. Training Training in prevention research, whether basic, epidemiological, trans- lational, or implementation, is not responsive to ongoing opportunity or needs. Workforce numbers remain insufficient to carry out research and ser- vice programs targeted to prevention of MEB disorders. The complexity of prevention efforts calls for more coordinated training in multidisciplinary settings. More and better investigators are needed in all areas, particularly in the field of implementation sciences. Recruitment of future leaders should be enhanced by attracting the most talented young investigators to preven- tion research, through NIH-supported multidisciplinary training programs. As discussed in Chapter 5, coordination among researchers from diverse disciplines, such as developmental neuroscience, developmental psycho- pathology and prevention science, as well as collaboration across institu- tions are needed to integrate expanding knowledge from these fields. Prevention training is neglected for a broad array of health professionals (doctors, nurses, psychologists, social workers) and for teachers as well as other school personnel, for whom prevention should be a priority issue. When mental health or substance abuse is included in a training curricu- lum, it tends to focus on diagnosis and treatment. Similarly, prevention and promotion content tends to emphasize general health over mental health concerns. Refinement and broad implementation of prevention interven- tions are likely to languish unless more extensive and robust training is realized.

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76 PREVENTING MENTAL, EMOTIONAL, AND BEHAVIORAL DISORDERS Conclusion: Most training programs in major disciplines, such as medi- cine, education, psychology, social work, and public health, do not include core components on the prevention of MEB disorders of young people, including how to identify and manage the risks and preclinical symptoms of these disorders. Recommendation 12-6: 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 train- ing should set relevant standards using available evidence on identifying and managing risks and preclinical symptoms of MEB disorders. Recommendation 12-7: 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 and accredit- ing training programs in specific disciplines, such as health (including mental health), education, and social work. Recommendation 12-8: 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 approaches. Training models should be applied in both research contexts involving multiple disciplines and multidisciplinary approaches to training providers that work with young people.