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Position Statement 48: Prevention of Mental Health and Substance Use Disorders in Young People
Mental Health America believes that there is no health without mental health, and that the promotion of mental health and the prevention of mental health and substance use conditions should be central to healthcare.[i ii] Studies show that half of those who will develop mental health disorders show symptoms by age 14.[iii iv] The time between prenatal development and early adulthood is crucial for the brain. Yet, despite this knowledge, the American healthcare system continues to ignore problems until they reach crisis levels. Instead of investing in prevention and early intervention programs and providing access to appropriate services, we tolerate unconscionable rates of suicide[v], school drop-out[vi], homelessness[vii], and involvement in the juvenile justice system[viii]. While we can and do work to provide mental health services and supports and to promote recovery for individuals in need, the overwhelming number of those struggling is a reminder of how often we wait too long to take action.
Evidence-based mental illness prevention programs have positive effects on children and family health as well as on multiple social health issues such as educational achievement, financial stability, building safe communities, and many other social goods. With such programs in place, mentally healthy children can take fuller advantage of learning opportunities, individuals can be more effective in their job performance, and youth can feel safer in their homes and in their neighborhoods. Overall, investing in mental health promotion and prevention of mental and substance use conditions is critical to improving health outcomes for individuals, communities, and the nation as a whole [ix x]
Mental health and substance use conditions affect large numbers of young people. According to the Institute of Medicine (“IOM”), almost one in five young people have one or more such conditions at any given time. A review of epidemiological literature indicates that mental illnesses are a developmental disorder, with fifty percent of lifetime diagnoses occurring in the mid-teens and with a U.S. median age of onset of 14 [xi]. Although symptoms occur during the two years prior to meeting diagnostic criteria, treatment lags diagnosis by an average of 10 years[xii]. Mental health conditions have life-long effects that include high psychosocial and economic costs, not only for the young people, but also for their families, schools, and communities. Beyond the financial costs, mental health and substance use conditions interfere with young people’s ability to accomplish developmental tasks, such as establishing healthy interpersonal relationships, succeeding in school, and making their way in the workforce.
In 2009, the IOM released its seminal report: “Preventing Mental, Emotional and Behavioral Disorders among Young People." [xiii] According to the IOM, clear windows of opportunity are available to prevent mental health and substance use conditions from developing into serious disorders before they occur. Risk factors are well established, preventive interventions have been rigorously tested and are available, and the first symptoms typically precede a disorder by 2 to 4 years. Because mental health and general health problems are interwoven, improvements in mental health will also improve overall health. Yet the approach has largely been to wait to act until a disorder is well-established and has already done considerable harm. All too often, opportunities are missed to use evidence-based approaches to prevent the occurrence of disorders, establish building blocks for healthy development in young people, and limit the environmental exposures that increase risk.
Interventions that prevent disorders before they manifest offer the best opportunity to protect young people. “Mental health promotion” was defined broadly by the IOM, consistent with international bodies like the World Health Organization, to include: “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." [xiv] Such interventions can be integrated with routine health care and wellness promotion in schools, families, and communities. School-wide Positive Behavior Support is a particularly promising approach to mental health promotion in schools.
(See MHA Position Statement 45, “Discipline and Positive Behavior Support in Schools”). Thus, wellness promotion, in addition to interventions that reduce the rate of problematic behaviors and those that reduce environmental risk, has become a new focus: changing “from thinking that youth problems are merely the principal barriers to youth development to thinking that youth development serves as the most effective strategy for the prevention of youth problems.” [xv]
Screening for risk in the family and for precursors of a disorder in young people is also essential. (See MHA Position Statement 41: Early Identification and Treatment,[xvi] which addresses this issue.) According to the IOM, a range of policies and practices that follow up on mental health promotion and “universal” prevention interventions by targeting young people with specific risk factors (“selective” or “indicated” interventions) have proven to be effective at reducing and preventing mental health and substance use disorders. But this position statement focuses on promotion and “universal” prevention, rather than on risk factor identification, screening and follow-up treatment, which are the critical next steps in the prevention agenda, covered in Position Statement 41.
Research demonstrates the value of:
- Strengthening families by teaching effective parenting skills; improving communication; and helping families deal with potential problems (such as substance use), disruptions (such as divorce) and adversities (such as parental mental illness or poverty).
- Strengthening individuals by building resilience and skills and improving cognitive processes and behaviors.
- Promoting mental health in schools by offering support to children encountering serious stresses; modifying the school environment to promote socially adaptive behavior; developing students’ skills at decision making, self-awareness, and conducting relationships; and coping with potential violence, aggressive behavior, and substance use.
- Promoting mental health through health care and community programs by promoting and supporting socially adaptive behavior, teaching coping skills, and targeting modifiable life-style factors that can affect behavior and emotional health, such as sleep, diet, activity and physical fitness, sunshine and light, and appropriate television and computer use.
The key to most of these approaches is to identify biological, psychological, and social factors that may increase risk. Some of these risks reside in specific characteristics of the individual or family environment (such as parental mental illness or substance abuse or serious family disruptions), but they also include social stresses such as poverty, violence, lack of safe schools, and lack of access to health care. Most risk factors tend to come in clusters and are associated with more than one disorder. Currently, treatment interventions tend to isolate single interventions focused on specific family adversities (bereavement, divorce, parental psychopathology, parental substance use, parental incarceration), but there is growing evidence that well-designed prevention interventions reduce a range of problems and disorders and that these efforts need to be sustained over the long term. These programs can help children, families, and schools build strengths that support well-being. A focus on prevention and wellness can have multiple benefits that extend beyond a single disorder.
Since the IOM report, the prevention knowledge base has continued to expand with new randomized controlled trials demonstrating the value of a variety of prevention approaches. The Society for Prevention Research has played an important role by providing a yearly conference and an excellent journal, Prevention Science, and by articulating positions on the importance of high quality prevention research. Another important focus is the increasing awareness of the need for effective dissemination and implementation of evidence-based preventions. It is through effective dissemination and implementation, prevention programs can have a population-level effect. However, effective dissemination and implementation of prevention programs are not possible without sufficient funding and research. The study of, dissemination, and implementation of prevention initiatives has come to be recognized as an important scientific endeavor. To succeed, state and local governments will need to invest in a robust information technology infrastructure that can better model population health and allow for rigorous evaluation of interventions.
The focus on prevention in the Affordable Care Act (ACA) is a strong first step in prioritizing prevention in healthcare. Its emphasis on prevention has the potential to support for many more individuals who will now have access to healthcare coverage and offers an opportunity for expansion of preventive interventions. For example, the ACA has expanded access to nurse home visitation services [xvii] that have been shown to improve the health and well-being of both infants born to low income first time mothers as well as to the mothers’ health and social functioning. Interventions to strengthen parenting and parents’ knowledge and skills are a particularly effective intervention for improving youth behavior.[xviii] Collocation of behavioral health within primary care also offers important opportunities for more wide-spread use of prevention. The support of prevention programs through the ACA is a critical recognition of the need for federal support for prevention. Ultimately, the federal government must move beyond separate grant funding for prevention and build prevention into mainstream health care to ensure adequate translation into practice. To support widespread implementation, health care will need to use quality measures that reward effective prevention, track the savings that prevention creates across sectors (such as correctional intuitions), and leverage these savings to further promote prevention and recovery, as with shared-savings models like Accountable Care Organizations.
There is an increasing awareness that there needs to be a strong focus on prevention and wellness from preconception on through early adulthood in order to lay a firm foundation for later general and mental health.[xix xx] However, to truly prioritize prevention, officials at the local, state, and federal levels all must play a role in mental health promotion and the prevention of mental health and substance use disorders. Many providers and agencies are responsible for the care, protection, or support of young people: the child welfare, education, and juvenile justice systems, as well as medical, mental health, and substance abuse providers and community organizations. Yet resources within these agencies are scattered, not coordinated, and often do not effectively support prevention programs or policies. No public system is formally charged with the responsibility of carrying out the critically important work of promoting health by fostering resilience and promoting well-being. The result is a patchwork that does not perform as an integrated system and fails to serve the needs of many young people and their families.
Leadership is necessary to make systematic prevention efforts a high priority in the health care system as well as an integral aspect of the network of local, state, and federal programs and systems that serve young people and families. Leaders at the national, state, and local levels need to pursue specific strategies, such as partnerships among families, schools, courts, health care providers, and local programs to create coordinated approaches that support healthy development, as described in the IOM report and in this position statement.
Call to Action
Mental Health America and its affiliates should prioritize advocacy of the following changes:
- Health care systems should use quality measures that they can track year-to-year when individuals come in for check-ups, but that predict long-term outcomes in the individual’s mental health and development. When providers have an incentive to improve outcomes across development, they will have more of an incentive to do prevention. A life span measure does not currently exist, but advocates should call for its development and use to be a top priority in health care reform.
- The U.S. government should fund a group similar to the U.S. Preventive Services Task Force (which recommends preventive care in clinical settings which must be covered without a co-pay under the Affordable Care Act), but that recommends preventative services in non-clinical settings for coverage that are cost neutral to the health care system in the long-term – ensuring that health plans pay for prevention when it improves outcomes but won’t cost more.
- The Centers for Medicare and Medicaid Innovation statute should be amended so that they can look at how to improve outcomes and reduce costs in funding outside of health care – such as corrections – and work with states to consider their cross-sector savings as well.
- Health plan carriers and health care organizations should make providers aware of the coverage mandates for behavioral health screens and provide a range of possible followup options for providers to share with individuals in addition to referral to specialty care. In addition, Medicaid agencies should publically report on rates of behavioral health screening, referral, and follow-up to demonstrate the extent to which the Early and Periodic Screening, Diagnosis, and Treatment provision is being implemented.
- State and local educational agencies should collect measures of Social and Emotional Learning or School Climate that are considered to be as important as traditional academic measures for schools.
- State or local governments should adopt decision-making systems like Pew-MacArthur’s Results First Initiative,[xxi] or community-level tools like Communities That Care[xxii] to help communities make more effective investments in preventive programs and track outcomes.
- Universities, community colleges, and other training programs should require competencies in evidence-based prevention for health care providers, health care administrators, educators, educational support staff, human resources professionals, and individuals involved in child care. These competencies should also be reflected in relevant credentialing standards.
- State Medicaid agencies should explore amending billing codes to allow for broader use of evidence based prevention services, such as providing psychoeducation to communities or to ancillary supports even if the beneficiary is not present. This would allow for services such as psychoeducation to a parent to help a child or as in Oregon and Washington where they creatively use Medicaid funding to support delivery of the Good Behavior Game in classrooms and the selective and indicated components of the Triple P Positive Parenting Program.[xxiii]
i Source: Institute of Medicine Committee on Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults, 2009.
ii As applied to young people, the term “mental health or substance use conditions” as used in this policy statement is intended to mean the same thing as the federal term “emotional or behavioral disturbance.”
iii Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27.
iv Paus, T., Keshavan, M., & Giedd, J. N. (2008). Why do many psychiatric disorders emerge during adolescence? Nature Reviews Neuroscience, 9(12), 947-957.
v Suicide Prevention. (2015, March 10). Retrieved from http://www.cdc.gov/violenceprevention/pub/youth_suicide.html
vi 30th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, 2008. (2011, December 1). Retrieved from https://www2.ed.gov/about/reports/annual/osep/2008/parts-b-c/30th-ideaarc.pdf
viii Better Solutions for Youth with Mental Health Needs in the Juvenile Justice System. (2014). Retrieved from http://cfc.ncmhjj.com/wp-content/uploads/2014/01/Whitepaper-Mental-Health-FINAL.pdf
ix Brown H. & Strugeon S. , “Healthy Start of Life and Reducing Early Risks. In: Hosman, C., Jané-Llopis, E., & Saxena S., Eds. Prevention of Mental Disorders: an Overview on Evidence-based Strategies and Programs. Oxford, Oxford University Press (2002).
x World Health Organization Prevention of Mental Disorders, Effective Interventions and Policy Options. (2004). http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf
xi Kessler, R.C., Amminger, G.P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Ustün, T.B., “Age of Onset of Mental Disorders: a Review of Recent Literature.” (2007) Curr. Opin. Psychiatry 20(4):359-64. http://www.ncbi.nlm.nih.gov/pubmed/17551351
xii Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., & Walters, E. E., “Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication.” (2005) Arch. Gen. Psychiatry 62:593-602. http://www.ncbi.nlm.nih.gov/pubmed/15939837
xiii Released on March 12, 2009. http://www.iom.edu/Reports/2009/Preventing-Mental-Emotional-and-BehavioralDisorders-Among-Young-People-Progress-and-Possibilities.aspx Mental Health America acknowledges the IOM for the basic outline of this position statement.
xiv Id., p. 67
xv Pittman, K.J. and Fleming, W.E., A New Vision: Promoting Youth Development. (Washington, DC: Center for Youth Development and Policy Research, Academy for Educational Development 1991), at 3 (emphasis supplied).
xviii Furlong M, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. Behavioural and cognitivebehavioral group-based parenting programs for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD008225. DOI:10.1002/14651858.CD008225.pub2
xix Center on the Developing Child at Harvard University (2016). Building Core Capabilities for Life: The Science Behind the Skills Adults Need to Succeed in Parenting and in the Workplace. Retrieved from www.developingchild.harvard.edu.
xxiii Steverman, S. & Shern, D. Financing Primary Prevention Interventions, (2014) Alexandria, VA: Mental Health America.