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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities 4 Using a Developmental Framework to Guide Prevention and Promotion Mental, emotional, and behavioral (MEB) disorders among young people, as well as the development of positive health, should be considered in the framework of the individual and contextual characteristics that shape their lives, as well as the risk and protective factors that are expressed in those contexts. This chapter begins by outlining a developmental framework for discussion of risk and protective factors that are central to interventions to promote healthy development and prevent MEB disorders. The conceptualization and assessment of positive aspects of development, referred to as developmental competencies, are examined as the scientific underpinnings for research on promotion of mental health. The chapter goes on to discuss research on risk factors and protective factors for MEB disorders, with attention given both to factors associated with multiple disorders and to the multiple factors associated with specific disorders. The emphasis is on identifying the implications of findings from this research for the design and evaluation of developmentally appropriate preventive interventions. Specific interventions targeting particular developmental stages are discussed in more detail in Chapter 6, and interventions targeting specific disorders as well as those designed to promote mental health are discussed in Chapter 7. A DEVELOPMENTAL FRAMEWORK Prevention and promotion for young people involve interventions to alter developmental processes. That makes it important for the field to be
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities grounded in a conceptual framework that reflects a developmental perspective. Four key features of a developmental framework are important as a basis for prevention and promotion: (1) age-related patterns of competence and disorder, (2) multiple contexts, (3) developmental tasks, and (4) interactions among biological, psychological, and social factors (Masten, Faden, et al., 2008; Cicchetti and Toth, 1992; Kellam and Rebok, 1992; Sameroff and Feise, 1990). Age-Related Patterns of Competence and Disorder Understanding the age-related patterns of disorder and competence is essential for developing interventions for prevention and promotion. Healthy human development is characterized by age-related changes in cognitive, emotional, and behavioral abilities, which are sometimes described in terms of developmental milestones or accomplishment of developmental tasks (discussed in further detail below). The period from conception to about age 5 represents a particularly significant stage of development during which changes occur at a pace greater than other stages of a young person’s life and the opportunity to establish a foundation for future development is greatest (National Research Council and Institute of Medicine, 2000; see also Chapter 5). Developmental competencies established in one stage of a young person’s life course establish the foundation for future competencies as young people face new challenges and opportunities. Adolescence introduces significant new biological and social factors that affect developmental competencies, particularly related to behavioral decision making. A solid foundation of developmental competencies is essential as a young person assumes adult roles and the potential to influence the next generation of young people. The age at which disorders appear also varies. For example, a national survey on the lifetime prevalence of mental disorders in the United States indicates that the median age of onset is earlier for anxiety disorders (age 11) and impulse control disorders1 (age 11) than for substance use disorders (age 20) and mood disorders (age 30) (Kessler, Berglund, et al., 2005). The majority of adults report the onset of their disorder by age 24 (Kessler, Berglund, et al., 2005), and evidence suggests that initial symptoms appear 2-4 years prior to onset of a full-blown disorder (see Chapter 2). Other studies also indicate that early onset of symptoms is associated with greater risk of adult disorders, including substance abuse and conduct disorder (Kellam, Ling, et al., 1998; Gregory, Caspi, et al., 2007). 1 Includes intermittent explosive disorder, oppositional defiant disorder, conduct disorder, and attention deficit hyperactivity disorder.
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities FIGURE 4-1 An ecodevelopmental model of prevention. SOURCE: Adapted from Weisz, Sandler, et al. (2005). Multiple Contexts Development occurs in nested contexts of family, school, neighborhood, and the larger culture (Bronfenbrenner, 1979). Therefore, interventions can occur in a range of settings and in multiple contexts. As illustrated in Figure 4-1, the range of intervention approaches includes promotion of healthy development, prevention of MEB disorders, and treatment of individuals who are experiencing disorders (the outer semicircle). These interventions occur in an ecological framework of human development in which the individual is nested within micro-systems that are in turn nested within a larger community and cultural (including linguistic) context (the central concentric circles). The ecological perspective is widely accepted
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities in the study of mental health, developmental psychopathology (Masten, Faden, et al., 2008), and prevention science (Kellam and Rebok, 1992; Weisz, Sandler, et al., 2005). Developmental Tasks Individuals encounter specific expectations for behavior in a given social context. These expectations have been referred to as social task demands or developmental tasks (Kellam and Rebok, 1992; Masten, Burt, and Coatsworth, 2006). Developmental tasks change across phases of development and may also differ by culture, gender, and historical period. Success or failure in meeting these developmental tasks is judged by natural raters (e.g., parents, teachers) as well as by young people themselves. Success with one developmental task can have serious consequences for success or difficulty in others and for the development of later problems and disorders. Developmental competence, discussed below, is strongly influenced by the concept of developmental tasks. Interactions Among Biological, Psychological, and Social Factors How young people develop—whether they develop mental, emotional, or behavioral problems or experience healthy development—is a function of complex interactions among genetic and other biological processes (discussed in more detail in Chapter 5), individual psychological processes, and multiple levels of social contexts. Although the precise biopsychosocial processes leading to most disorders are not fully understood, considerable progress has been made in identifying the risk factors and protective factors that predict increased or decreased likelihood of developing disorders. Understanding the pathways of development enables prevention researchers to identify opportunities to change pathological developmental trajectories. A DEVELOPMENTAL PERSPECTIVE ON THE STUDY OF MENTAL HEALTH PROMOTION Mental health promotion includes efforts to enhance individuals’ ability to achieve developmentally appropriate tasks (developmental competence) and a positive sense of self-esteem, mastery, well-being, and social inclusion and to strengthen their ability to cope with adversity. Understanding the reciprocal pathways by which failures of competence contribute to psychopathology and by which psychopathology undermines healthy development (Masten, Burt, and Coatsworth, 2005) is needed to design promotion activities aimed at strengthening developmental competencies. Research on mental health promotion is not as fully developed as that
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities on prevention, but progress has been made in defining key concepts and describing biopsychosocial pathways that influence positive development. Important opportunities exist for research to make rapid advances, particularly to improve understanding of how genetic and environmental factors influence developmental pathways (National Research Council and Institute of Medicine, 2000, p. 13). The discussion that follows focuses on competence or the achievement of developmentally appropriate tasks, which the committee contends should form the basis for mental health promotion research and intervention, and characteristics of healthy development as young people progress from infancy through young adulthood that can be used to operationalize competence. Defining Competence Masten and colleagues define competence as “a family of constructs related to the capacity or motivation for, process of, or outcomes of effective adaptation in the environment, often inferred from a track record of effectiveness in age-salient developmental tasks and always embedded in developmental, cultural and historical context” (Masten, Burt, and Coatsworth, 2006, p. 704). Similarly, Kellam, Branch, and colleagues (1975) conceptualize competence from a life-course social field perspective, in which the individual must adapt to new tasks in different social fields (e.g., family, school, peers) at each phase of development. Positive youth development can be viewed as the facilitation of competence during adolescence. Based on a comprehensive review of youth development programs and meetings of experts, Catalano, Berglund, and colleagues (2004) identified multiple goals of programs designed to promote positive youth development: promote bonding; foster resilience; promote social, emotional, cognitive, behavioral, and moral competence; foster self-determination, spirituality, self-efficacy, clear and positive identity, belief in the future and prosocial norms; and provide recognition for positive behavior and prosocial involvement. The committee uses the term “developmental competencies” to refer to young people’s ability to accomplish a broad range of social, emotional, cognitive, moral, and behavioral tasks at various developmental stages. Acquisition of competence in these areas requires young people to adapt to the demands of salient social contexts and to attain a positive sense of identity, efficacy, and well-being. We note, however, that while there is increasing interest in understanding and promoting these positive aspects of development (e.g., Commission on Positive Youth Development, 2005), research in this area is at a relatively early stage. At the same time, research is beginning to identify factors that affect success or failure in accomplishing specific developmental tasks and the relationship to later development of problems
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities or health. For example, various causal models of the links between conduct and academic competence have been developed (e.g., see Hinshaw, 1992). One longitudinal study of a community cohort of 205 children assessed three dimensions of competence in childhood (academic, social, and conduct) and five dimensions of competence in late adolescence (academic, social, conduct, job, and romantic) (Project Competence; Masten, Burt, and Coatsworth, 2006). Conduct competence (following rules in salient social contexts) in childhood proved to be more likely to lead to academic competence in adolescence than the reverse pathway (see Hinshaw, 1992, for a discussion of alternative causal models of the links between conduct and academic competence). Masten and colleagues proposed the concept of developmental cascades to refer to the process by which competence and problems become linked across time. Illustratively, their study found externalizing, or primarily behavioral, problems (e.g., conduct disorder, oppositional defiant disorder) in childhood leads to lower academic competence in adolescence, which in turn leads to increased internalizing, or primarily emotional, problems (e.g., anxiety, depression) in young adulthood (Masten, Roisman, et al., 2005). In another study of 1,438 adolescents in two urban, high-poverty public schools in Baltimore and New York (Seidman and Pedersen, 2003), competence was conceptualized as the interaction of the individual with several social contexts: peer, athletic, academic, religious, employment, and cultural. Nine different profiles of engagement with these contexts emerged and showed differing associations with indicators of positive mental health (self-esteem) and mental health problems (depression and delinquency). Youth who were positively engaged in two or more settings had higher self-esteem and lower depression. However, high engagement in athletic contexts along with low engagement in cultural or academic contexts was associated with high rates of delinquency. These authors propose that studying homogeneous at-risk populations can identify diverse profiles of competence (positive or negative) that might be obscured by studying more heterogeneous populations or by studying each aspect of competence separately (Seidman and Pedersen, 2003). Werner and Smith (1982, 1992), in a series of classic studies of youth at high risk on the island of Hawaii, also argue that the resources a child needs to successfully develop vary by developmental stage. Early in life, a close relationship with the primary caregiver is crucially important, whereas in adolescence, the presence of mentors and opportunities in school and the neighborhood are crucial. Characteristics of Healthy Development Although there are no universally accepted taxonomy or agreed-on measures of positive mental health, several groups have attempted to inte-
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities grate research and theory on healthy development at different developmental stages. Table 4-1 summarizes findings related to individual, family, and school and community characteristics that facilitate healthy development from reviews that the committee considers to be particularly informative. These factors differ across developmental periods and across individual, family, and school and community contexts. For a guide to factors relevant during infancy and early childhood, the committee looked to the influential report From Neurons to Neighborhoods: The Science of Early Childhood Development (National Research Council and Institute of Medicine, 2000). Healthy accomplishment of the developmental tasks at these ages—such as secure attachment, emotional regulation, executive functioning, and appropriate conduct—is associated with both positive development and prevention of mental, emotional, and behavioral problems over the long term. The report highlighted the influence of families’ socioeconomic resources on healthy development, suggesting that promotion (and prevention) research should include consideration of the influence of poverty on children’s caregivers and their physical environment. The committee drew from several sources on positive development during middle childhood. Masten and Coatsworth (1995) assessed competent functioning in middle childhood in terms of successfully accomplishing developmental tasks, such as academic achievement, following rules for appropriate behavior, and developing positive peer relations. Resilience, or the ability to adapt to life stressors, is a widely accepted aspect of positive development (Catalano, Berglund, et al., 2002; Commission on Positive Youth Development, 2005; Masten, Burt, and Coatsworth, 2005). The Rochester Child Resilience Project identified characteristics of the child and of the family that are associated with resilience for urban children experiencing chronic family stress (Wyman, 2003). The school is also a social context that can promote the accomplishment of the developmental tasks of academic achievement, rule compliance, and the development of peer relations, as described by Masten and Coatsworth (1995). Aspects of the school context identified by Smith, Swisher, and colleagues (2004) as promoting children’s developmental competencies include teacher behavior, pedagogy, organizational characteristics of the school, and family-school relations. A major review of community programs to promote positive outcomes for adolescent development identified four domains of individual-level assets: physical health, intellectual development, psychological and emotional development, and social development (National Research Council and Institute of Medicine, 2002). The review also identified features of positive developmental settings, which the committee sees as relevant both for the family and for school and the community. Some of these include
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities TABLE 4-1 Factors That Affect Healthy Development Individual Family School and Community Infancy and Early Childhood NRC and IOM (2000) Self-regulation -Attention regulation -Appropriate emotional inhibitions and expression -Early mastery and intrinsic motivation -Executive functioning, planning, and problem solving -Secure attachment NRC and IOM (2000) Healthy physical environment -Adequate prenatal and postnatal health care -Adequate prenatal and postnatal nutrition NRC and IOM (2000) Availability of high-quality child care -Nurturance -Support for early learning -Access to supplemental services, such as feeding, screening for vision and hearing, support for working parents -Stable secure attachment to child care provider -Low ratio of caregivers to children -Regulatory systems that support high quality of care Nurturing relationships with caregiver including: -Reliable support and discipline from caregiver -Responsiveness -Protection from harms and fears -Affection -Opportunities to resolve conflict -Support for development of new skills -Reciprocal interactions -Experience of being respected -Stability and consistency in caregiver relationship Communication and learning -Functional language -School attendance and appropriate conduct Making friends and getting along with peers -Initiating interactions and appropriate conduct -Understanding of self and others’ emotions Adequate birth weight Socioeconomic resources for the family -Adequate income -Ability to provide adequate nutrition, child care, safe housing, health care -Higher parental education -Cognitive stimulation in the home -Parental low economic stress
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities Middle Childhood Masten and Coatsworth (1995) -Learning to read and write a language -Learning basic mathematics -Attending and behaving appropriately at school -Following rules for behavior at home, school, public places -Getting along with peers in school -Making friends with peers Wyman (2003) -Time in emotionally responsive interactions with children -Consistent discipline -Language-based rather than physically based discipline -Extended family support -Parental resources, including positive personal efficacy, adaptive coping, self-views high on potency and life satisfaction Smith, Boutte, et al. (2004) Features of school environment that are associated with positive development -Positive teacher expectancies -Perceived teacher support -Effective classroom management -Positive partnering between school and family -Culturally relevant pedagogy -School policies and practices to reduce bullying -High academic standards, strong leadership, concrete strategies to promote achievement, assessment of goal achievement, and positive involvement of families Wyman (2003) -Empathy and acceptance of other children’s emotional expressiveness -Preference for prosocial solutions to interpersonal problems -Realistic control attributions -Self-efficacy
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities Individual Family School and Community Adolescence NRC and IOM (2002) Positive development in adolescence -Physical development (good health habits, good health risk management skills) -Intellectual development (life, school, vocational skills; critical and rational thinking; cultural knowledge and competence) -Psychological and emotional (self-esteem and self-regulation; coping, responsibility, problem solving; motivation and achievement; morality and values) -Social development (connectedness to peers, family, community; attachment to institutions) NRC and IOM (2002) Features of positive developmental settings -Physical and psychological safety -Appropriate structure (limits, rules, monitoring, predictability) -Supportive relationships -Opportunities to belong (sociocultural identity formation, inclusion, etc.) -Positive social norms (expectations, values) -Support for efficacy and mattering -Opportunities for skill building -Integration of family, school, and community efforts NRC and IOM (2002) Features of positive developmental settings -Physical and psychological safety -Appropriate structure (limits, rules, monitoring, predictability) -Supportive relationships -Opportunities to belong (sociocultural identity formation, inclusion, etc.) -Positive social norms (expectations, values) -Support for efficacy and mattering -Opportunities for skill building -Integration of family, school, and community efforts Young Adulthood Arnett (2000) Identity exploration in love, work, and world view Subjective sense of adult status in self- sufficiency, making independent decisions, becoming financially independent Arnett (2000) Balance of autonomy and relatedness to family Arnett (2000) Opportunity for exploration in work and school Masten, Obradovic, and Burt (2006) Autonomy (behavioral and emotional) Masten, Obradovic, and Burt (2006) Connectedness to adults outside the family Masten, Obradovic, and Burt (2006) Future orientation/achievement motivation
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities physical and psychological safety, supportive relationships, and positive social norms (National Research Council and Institute of Medicine, 2002). However, the committee notes the review’s caveat that additional research is needed to more firmly establish whether these features of positive developmental settings “are the most important features of community programs for youth” (National Research Council and Institute of Medicine, 2002, p. 13). Arnett (2000) describes the period of the late teens and early 20s as a distinct developmental period in industrialized societies, which he refers to as “emerging adulthood.”2 In these societies, a major demographic shift toward later marriage and parenthood is leaving young adulthood as an age of great variability and exploration in all aspects of life, including where people live, go to school, and work. The developmental tasks of this period are to explore identity in love, work, and world view (e.g., values); to obtain a broad range of life experiences; and to move toward making commitments around which to structure adult life (Arnett, 2000). This work on early adult development continues the tradition of others (e.g., Erikson, 1968; Levinson, 1978) and illustrates the important influence on developmental tasks of modern economic and social conditions in industrialized societies. A DEVELOPMENTAL PERSPECTIVE ON RISK AND PROTECTIVE FACTORS Preventive interventions for young people are intended to avert mental, emotional, and behavioral problems throughout the life span. These interventions must be shaped by developmental and contextual considerations, many of which change as children progress from infancy into young adulthood. To develop effective interventions, it is essential to understand both how developmental and contextual factors at younger ages influence outcomes at older ages and how to influence those factors. The concept of risk and protective factors is central to framing and interpreting the research needed to develop and evaluate interventions. Defining Risk and Protective Factors Kraemer, Kazdin, and colleagues (1997) define a risk factor as a measurable characteristic of a subject that precedes and is associated with an outcome. Risk factors can occur at multiple levels, including biological, psychological, family, community, and cultural levels. They differentiate 2 The committee uses the term “young adulthood” to be more descriptive and to cut across different theoretical approaches.
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities Family Dysfunction and Disruption. With the family as the primary setting for child development from birth through childhood and adolescence, it is not surprising that dysfunction in family relations, particularly parent–child relations, is associated with multiple mental, emotional, and behavioral problems, including those described above. Many risk factors (e.g., poverty, parental mental illness) influence mental, emotional, and behavioral problems and disorders through their effects on parent–child relations (Grant, Compas, et al., 2003; Riley, Valdez, et al., 2008). The discussion here focuses on two broad categories of risk factors that are related to dysfunctional family relations and that provide opportunities for preventive intervention: child maltreatment, which represents the extreme manifestation of family dysfunction, and disruptions in family structure, which create serious challenges to healthy family functioning. Child Maltreatment. Maltreatment of children by primary caregivers is one of the most potent risk factors for mental, emotional, and behavioral problems, and it has been found to be associated with other serious risk factors, such as poverty and parental mental illness. Protective factors include children’s positive relationship with an alternative caregiver, positive and reciprocal friendships, and higher internal control beliefs (Bolger and Patterson, 2003). The prevalence of child maltreatment in the United States is unclear. One estimate places it at 1.2 percent of children in 2004 (National Child Abuse Data System). Hussey, Chang, and Kotch (2006) report that 11.8 percent of adolescents report physical neglect, 28.4 percent report physical assault by a parent or caregiver, and 4.5 percent report sexual abuse by a parent or caregiver sometime before they reached the sixth grade. In the National Longitudinal Study of Adolescent Health (Add Health), which includes a nationally representative sample of adolescents, each form of maltreatment was associated with multiple health problems, including depression, substance use, violence, obesity, and poor physical health (Hussey, Chang, and Kotch, 2006). The majority of these associations remained significant after controlling for such demographic variables as family income, age, gender, ethnicity, parent education, region, and immigrant generation (Hussey, Chang, and Kotch, 2006). In a recent empirical examination in the National Comorbidity Study (Molnar, Buka, and Kessler, 2001), one of the largest and most methodologically sound studies, childhood sexual abuse was reported by 13.5 percent of the women and 2.5 percent of the men. Significant associations were found with 14 mood, anxiety, and substance abuse disorders among women and 5 disorders among men. The analysis controlled for other adversities, including divorced parents, parental psychopathology,
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities parental verbal and physical abuse, parental substance use problems, and having dependents for women. The lifetime rate of depression was 19.2 percent for those with no childhood sexual abuse and 39.3 percent for those who had experienced abuse (odds ratio = 1.8; Molnar, Buka, and Kessler, 2001). Rates of dysthymia, mania, and posttraumatic stress disorder were also significantly higher for sexually abused women but not for men. The impact of childhood sexual abuse was especially strong for those who had no other adversities; their odds for depression were 3.8 (95 percent confidence interval). For those who reported 5 or more adversities, the odds of depression were 1.7 (95 percent confidence level). There was some evidence that chronic sexual abuse led to higher rates of some disorders (Molnar, Buka, and Kessler, 2001). Parental psychopathology, especially among mothers, was the most significant family adversity associated with abuse (Molnar, Buka, and Kessler, 2001) and warrants further investigation. However, finding high rates of disorder with abuse but no other risk factors emphasizes the importance of the negative effects of abuse. The persistence of negative effects of child maltreatment is seen in studies that assess functioning across periods of development. For example, the Virginia Longitudinal Study of Child Maltreatment found that of 107 maltreated children who were followed from middle childhood through early adolescence, fewer that 5 percent were functioning well consistently over time (Bolger and Patterson, 2003). Understanding the factors that influence the linkage between child maltreatment and problem outcomes starts by distinguishing different levels of abuse. In particular, abuse that starts early and is chronic is linked with pervasive and persistent problems across domains of functioning. Children abused in infancy show difficulties in areas that include affect regulation (e.g., high negative affect, blunted affect), hypervigilance, emotional lability, disruptions in their attachment relations, and self-system deficits (e.g., more negative self-representations) (Ialongo, Rogosch, et al., 2006). The most effective approach to reducing the effects of maltreatment is to prevent its occurrence. Because of the pervasive mental, emotional, and behavioral problems for which maltreated children are at risk, programs that prevent abuse have the potential to avert multiple disorders and promote healthy development across multiple domains of functioning. There is evidence, for example, that a home visiting program for economically poor, single parents has been effective in reducing the occurrence of child abuse (Olds, 2006; see Box 6-1) and that a population-level approach to strengthening parenting reduces rates of abuse in the community (Prinz, Sanders, et al., 2009). Interventions are also aimed at mitigating the impact of abuse after it has occurred. Several randomized trials with maltreated children demonstrated that infant and preschool psychotherapy and a home visiting program were successful in markedly reducing rates of insecure attachment
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities (Ialongo, Rogosch, et al., 2006). Other program models have demonstrated success to improve maltreated children’s relationships with foster parents (Fisher, Gunnar, et al., 2000) and with well-functioning peers (Fantuzzo, Sutton-Smith, et al., 1996). Family Disruption. Family disruption can occur for many reasons, including separation or divorce, the death of a parent, and incarceration of a parent. The committee focused on parental divorce and bereavement because they have been the subject both of considerable research and of preventive trials. The rate of divorce in the United States increased from the 1950s through the 1970s and then stabilized or decreased somewhat over the following decades (Bramlett and Mosher, 2002; U.S. Census Bureau, 2005). However, the official divorce rate underestimates the rate of marital disruption, which may occur as separations that do not become divorces or as disruptions of households with unmarried parents (Bramlett and Mosher, 2002). It is estimated that 34 percent of children in the United States will experience parental divorce before reaching age 16 (Bumpass and Lu, 2000). Children can experience a wide range of other stressors following divorce, such as loss of time with one or more parents, continuing interparental conflict, and parental depression (Amato, 2000). Evidence suggests that effective child coping or interpretation of these stressors, quality of parenting received from both parents, and level of interparental conflict is related to postdivorce adjustment (e.g., Kelly and Emery, 2003; Sandler, Tein, et al., 2000). Death of a parent (i.e., parental bereavement) occurs to 3.5 percent of U.S. children before age 18 (U.S. Social Security Administration, 2000). The effect of parental death on surviving children rises to national concern particularly when rates increase due to such national disasters as the terrorist attacks of September 11, 2001, war, and such epidemics as HIV. Following parental divorce, children are at increased risk for multiple mental, emotional, and behavioral problems, including physical health problems, elevated levels of alcohol and drug use, premarital childbearing, receiving mental health services, and dropping out of school (Troxel and Matthews, 2004; Furstenberg and Teitler, 1994; Hoffmann and Johnson, 1998; Goldscheider and Goldscheider, 1993; Hetherington, 1999). Meta-analyses of studies conducted through the 1990s have shown that problems have not decreased (Amato and Keith, 1991a; Amato, 2001). McLanahan’s (1999) analysis of 10 national probability samples revealed school dropout rates of 31 percent and teen birth rates of 33 percent for adolescents in divorced families versus 13 and 11 percent, respectively, for adolescents in nondivorced families. Adults who were exposed to parental divorce as children have been found to be more likely to divorce and to have an increased
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities risk for mental, emotional, and behavioral problems, including clinical levels of mental health problems, substance abuse, and mental health service use (Chase-Lansdale, Cherlin, and Kiernan, 1995; Kessler, Davis, and Kindler, 1997; Maekikyroe, Sauvola, et al., 1998; Rodgers, Power, and Hope, 1997; Zill, Morrison, and Coiro, 1993; Amato, 1996). Children who experience parental bereavement appear more likely to experience mental, emotional, and behavioral problems, such as depression, posttraumatic stress disorder, and elevated mental health problems for up to two years following the death (Worden and Silverman, 1996; Geresten, Beals, and Kallgren, 1991). These risks appear to remain after controlling for other risk factors, such as mental disorder of the deceased parent (Melhem, Walker, et al., 2008). Research has shown mixed findings concerning the mental, emotional, and behavioral problems of bereaved children when they reach adulthood (Kessler, Davis, and Kindler, 1997). However, two prospective longitudinal studies supported increased risk of depression in adult women who experienced parental bereavement as children (Reinherz, Giaconia, et al., 1999; Maier and Lachman, 2000). Although family disruption is associated with multiple MEB disorders and problems, the majority of children who experience these major stressors adapt well. The most consistent predictive factors are interparental conflict and the quality of parenting by both the mother and the father (Kelly and Emery, 2003; Amato and Keith, 1991b). Parent–child relations that are characterized by warmth, positive communication and supportiveness, and high levels of consistent and appropriate discipline have consistently been related to better outcomes following divorce (Kelly and Emery, 2003; Amato and Keith, 1991b). High-quality parenting from both the custodial parent (usually the mother) and the noncustodial parent (usually the father) is related to lower levels of child internalizing and externalizing problems (King and Sobolewski, 2006). But interparental conflict is one of the most damaging stressors for children from divorced families. Conflict often precedes the divorce and is associated with lasting child problems following the divorce (Block, Block, and Gjerde, 1988). In some families, conflict continues long after divorce, which is particularly destructive when children are caught in the middle (Buchanan, Maccoby, and Dornbusch, 1991). Recent research has found that high-quality parenting from both parents related to lower child mental health problems even in the presence of high interparental conflict (Sandler, Miles, et al., 2008). Several factors have been found to influence outcomes for children who experience parental bereavement. Among parentally bereaved children who had signed up for an intervention program, four factors distinguished bereaved children who had clinical levels of mental health problems from those who did not: positive parenting by the surviving caregiver, lower mental health problems of the surviving parent, the coping efficacy of
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities the child, and children’s appraisals of how much recent stressful events threatened their well-being (Lin, Sandler, et al., 2004). Other factors, such as coping efficacy, control beliefs, postbereavement stressful events, and children’s fears that they will be abandoned by the surviving caregiver, have been associated with mental health outcomes for bereaved children (Wolchik, Tein, et al., 2006). An interesting focus of research has investigated the pathways that lead from family disruption due to divorce or bereavement, along with other commonly co-occurring biological and social risk factors, to adult depression. One analysis of longitudinal data on female twins, siblings, and unrelated women found support for three pathways to the development of depression (Kendler, Gardner, and Prescott, 2002). In an internalizing pathway, genetic risk leads to neuroticism, which in turn leads to early-onset anxiety disorder, and these three influences each lead to episodes of major depression. In an externalizing pathway, conduct disorder and substance misuse lead to depressive disorder. In an adversity pathway, early childhood exposure to a disturbed family environment, childhood sexual abuse, and parental loss lead to low educational attainment, lifetime trauma, and low social support, which in turn lead to four adult risk factors (marital problems, difficulties in the past year, dependent stressful events, and independent stressful events), which in turn lead to an episode of major depression. All three pathways include contributions from genetic factors and interconnections among family adversity, externalizing problems, and later adult adversities. A prospective longitudinal study, the National Collaborative Perinatal project, also considered timing in an examination of the association between family disruption (divorce or separation before age 7), low socioeconomic status, and residential instability and the onset of adult depression (Gilman, Kawachi, et al., 2003). The effect of low socioeconomic status in childhood on depression risk persisted into adulthood, but the effects of family disruption and residential instability were specific to early-onset depression. Early-onset depression is of special concern because it carries with it a poorer prognosis of increased recurrence and, in some studies, more severe depressions. Community and School Risk Factors Most prevention research has focused on risk and protective factors at the level of the individual and the family, but there is increasing recognition that child development is powerfully affected by the broader social contexts of schools and communities (Boyce, Frank, et al., 1998). Risk factors, such as victimization, bullying, academic failure, association with deviant peers, norms and laws favoring antisocial behavior, violence, and
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities substance use, are linked primarily with neighborhoods and schools. For example, poor and ethnic minority children in particular are frequently exposed to violence in their neighborhoods and schools. Among 900 low-income, primarily minority adolescents in New York City in 2002-2003, rates of exposure to violence of various kinds were high: someone offering or using drugs (70 percent), someone beaten or mugged (51 percent), someone being stabbed (17 percent), someone being shot at (14 percent), and someone being killed (12 percent) (Gershoff, Pedersen, et al., 2004). Many also reported being the victim of violent acts, such as being asked to sell or use drugs (35 percent), having their home broken into (18 percent), being beaten up (13 percent), and being threatened with death (9 percent). Much of the exposure to violence occurs either at school or on the way to school (DeVoe, Peter, et al., 2003; Bell and Jenkins, 1991; Richters and Martinez, 1993; Gershoff, Aber, and Raver, 2003). Exposure to violence is associated with children’s development of various mental health problems, particularly posttraumatic stress disorder, anxiety, depression, antisocial behavior, and substance use (Jenkins and Bell, 1994; Gorman-Smith and Tolan, 1998). A reciprocal relation exists between academic achievement and mental health outcomes, in which mental health problems adversely affect academic achievement (Adelman and Taylor, 2000), and poor academic achievement is related to the development of multiple problem behaviors (e.g., substance abuse, antisocial behavior) as well as teenage pregnancy and low occupational attainment (Dryfoos, 1990). The growing empirical research on characteristics of neighborhoods and schools that are linked with problem development as well as positive youth development has implications for the development and evaluation of prevention and promotion interventions. Gershoff, Aber, and Raver (2003) propose that another dimension of schools and neighborhoods that may affect the development of child mental, emotional, and behavioral problems is the degree to which they provide settings that support healthy development. They characterize neighborhood disadvantage as the absence of settings that provide opportunities for healthy child development—settings for learning (e.g., libraries), social and recreational activities (e.g., parks), child care, quality schools, health care services, and employment opportunities. For schools, disadvantage can be assessed as lower per student spending, a high percentage of children from families in poverty, a higher number of inexperienced and academically unprepared teachers, a high student-to-teacher ratio, and school size being either too large or too small. Each of these characteristics of neighborhoods and schools has been linked with mental, emotional, and behavioral problems of children. Although it is difficult to disentangle the causal effects of neighborhood and school disadvantage from the effects of factors in families and children who live in disadvantaged neighborhoods, research has found that neighborhood
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities disadvantage was associated with higher internalizing and externalizing problems over and above the genetic contribution (Caspi, Taylor, et al., 2000) and that an experimental study found that children whose families were moved from a disadvantaged neighborhood had a lower rate of arrest for a violent crime than those who remained in a high-poverty neighborhood (Leventhal and Brooks-Gunn, 2003). Similarly, the strongest environmental association related to schizophrenia is urbanicity (Krabbendam and van Os, 2005), although the relation with social class is also strong. It appears that living in urban environments during childhood affects later development of schizophrenia, even if there is a move to less urban environments later in life (Pederson and Mortensen, 2001). This relationship is therefore not fully explained by the “drift” hypothesis, in which those who are developing schizophrenia move to urban settings. There are a few hypotheses that are being pursued to explain this relationship, including increased stress and discrimination against minorities, lack of social capital and other resources in impoverished communities, and gene–environment interactions. Another way in which the community influences child development is through the norms, values, and beliefs of the residents. For example, collective efficacy, a concept developed by Sampson, Raudenbush, and Earls (1997), refers to “shared beliefs in a neighborhood’s conjoint capability for action to achieve an intended effect, and hence an active sense of engagement on the part of residents.” It provides the informal social controls that counteract antisocial behavior and has been found to be related to levels of community violence (Sampson, 2001). Peer norms favoring the use of drugs, antisocial behavior, or belonging to gangs are also powerful neighborhood factors that contribute to problem behaviors. Hawkins and Catalano (1992) proposed the construct of bonding to school, community, and family as key in explaining the development of substance use and antisocial behavior. Positive bonds consist of a positive relationship, commitment, and belief about what is healthy and ethical behavior. Positive bonds to a group develop from having the opportunity to be an active contributor, having the skills to be successful, and receiving recognition and reinforcement for their behavior. In school, students’ relationships with their peers and teachers and the social climate in the classroom have a powerful effect on their development of mental, emotional, and behavioral problems as well as their development of age-appropriate competencies. For example, aggregate-level student-perceived norms favoring substance use, violence, or academic achievement are related to antisocial behavior. For boys with elevated levels of externalizing problems, being in a first grade classroom with high aggregate levels of behavior problems has been found to be associated with a marked increase in the odds of having serious externalizing problems when they reached the
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities sixth grade (Kellam, Ling, et al., 1998). But some teacher characteristics are related to lower levels of mental, emotional, and behavioral problems for students. These include using classroom management strategies with a low level of aggressive behavior, having high expectations for students, and having supportive relations with students. Programs promoting classroom and school procedures that encourage prosocial behavior, academic achievement, or increased positive bonding to school have important implications for children’s healthy development. For example, use of a group contingency to promote prosocial behavior in first grade students has been found to reduce aggressive behavior in first grade (Dolan, Kellam, et al., 1993) and through middle school (Muthén, Brown, et al., 2002). The effects persisted with a reduction 13 years later in the rate of diagnosis of alcohol and illicit drug abuse or dependence (Kellam, Brown, et al., 2008). Also, for the subgroup of boys who started first grade with high levels of aggressive behavior, this intervention reduced the rate of antisocial personality disorder (Petras, Kellam, et al., 2008) and mental health service use (Poduska, Kellam, et al., 2008). Structural and policy changes can reduce risk associated with the transition to senior high school (Seidman, Aber, and French, 2004). This transition is associated with a decline in academic performance as well as an increase in delinquency, depression, suicidal thoughts, and substance use. However, policy changes, such as reduced school size, that create smaller working units with more supportive relations with teachers and peers have been shown to reduce this risk (Felner, Brand, et al., 1993). CONCLUSIONS AND RECOMMENDATIONS A voluminous literature has emerged since the 1994 IOM report on the factors associated with MEB disorders in young people, with a consensus that these factors operate at multiple interrelated levels. Factors both specific to a given disorder and that provide a more generalized risk for multiple disorders provide important opportunities for the development of interventions that modify these factors and explore possible mediating mechanisms. Conclusion: Research has identified well-established risk and protective factors for MEB disorders at the individual, family, school, and community levels that are targets for preventive interventions. However, the pathways by which these factors influence each other to lead to the development of disorders are not well understood. Conclusion: Specific risk and protective factors have been identified for many of the major disorders, such as specific thinking and behavioral
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities patterns for depression or cognitive deficits for schizophrenia. In addition, nonspecific factors, such as poverty and aversive experiences in families (e.g., marital conflict, poor parenting), schools (e.g., school failure, poor peer relations), and communities (e.g., violence), have been shown to increase the risk for developing most MEB disorders and problems. A more recent science base has solidified around the concept of developmental competencies that could inform the development of future interventions focused on the promotion of mental, emotional, and behavioral health. Conclusion: Interventions designed to prevent MEB disorders and problems and those designed to promote mental, emotional, and behavioral health both frequently involve directly strengthening children’s competencies and positive mental health or strengthening families, schools, or communities. However, improved knowledge pertaining to the conceptualization and assessment of developmental competencies is needed to better inform interventions. The ways in which developmental competencies operate in a health-promoting capacity is less well understood, and additional research is needed to develop common measures that can be used in intervention research. Recommendation 4-1: Research funders led by the National Institutes of Health, should increase funding for research on the etiology and development of competencies and healthy functioning of young people, as well as how healthy functioning protects against the development of MEB disorders. Recommendation 4-2: The National Institutes of Health should develop measures of developmental competencies and positive mental health across developmental stages that are comparable to measures used for MEB disorders. These measures should be developed in consultation with leading research and other key stakeholders and routinely used in mental health promotion intervention studies. Current knowledge on the development of MEB disorders among young people and characteristics of healthy development suggest the need for multiple lines of inquiry for future preventive intervention research.
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Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities Recommendation 4-3: Research funders should fund preventive intervention research on (1) risk and protective factors for specific disorders; (2) risk and protective factors that lead to multiple mental, emotional, and behavioral problems and disorders; and (3) promotion of individual, family, school, and community competencies.
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