Advocates for stronger efforts to prevent mental, emotional, and behavioral disorders in children are beginning the new decade with momentum.

The National Research Council and the Institute of Medicine are among the latest voices to call for a shift in policy and practice toward addressing the roots of mental, emotional, and behavioral problems rather than waiting until a disorder is well established and has caused harm. A March 2009 report published by the influential National Academies concluded that preventing such problems and promoting the mental health of children should be a national priority.

Such a shift presents a number of challenges for behavioral science, educators and those who make and implement public policy. Chief among them is embracing the early childhood years—when the quality of a child’s environment, relationships, and other experiences have a profound impact on development and later outcomes—as a window of opportunity to prevent mental, emotional, and behavioral problems later in life.

"It is a new way of thinking for everyone involved," said Ray Firth, director of the Division of Policy Initiatives at the University of Pittsburgh Office of Child Development (OCD). “In psychology, there had been the nature-versus-nurture debate. Now, it’s the interaction of the two.”

Allegheny County appears to be ahead of the curve when it comes to adopting approaches focused on preventing a problem from occurring in the first place. Prevention has gained traction in the county over the past decade as a prudent way of addressing issues related to children and families such as school readiness, social-emotional problems, and maternal depression.

Mental, emotional, and behavioral disorders among children, adolescents, and young adults can range from depression to conduct disorders and substance abuse. These problems impose serious hardships on children and on their families and society as well.

Such disorders are not uncommon among that population. Studies cited in the National Academies report suggest that between 14 percent and 20 percent of children, adolescents, and young adults experience a mental, emotional, or behavioral disorder at a given point in time. For example, one study found that in 2006 an estimated 21 percent of adolescents ages 12-17 years received treatment or counseling for mental, emotional, and behavioral problems.

Signs of these problems can be seen at an early age, even before age 5. Evidence suggests, for instance, that the rate of expulsion from preschool programs for behavioral problems is higher than expulsion rates for behavioral problems in grades kindergarten through 12.

Failure to address these disorders can be devastating to the child and costly to the nation, the National Academies report suggests. Early onset of mental, emotional, and behavioral problems predicts lower school achievement, a higher burden on the child welfare system, and greater demands on the juvenile justice system. Early aggressive behavior increases the risk of conduct disorder and later drug use. And one estimate cited in the report suggests the costs associated with mental, emotional, and behavioral problems in the United States totaled $247 billion in 2007 alone.

Research provides strong support for addressing these problems during childhood. Studies suggest, for example, that half of all mental, emotional, and behavioral disorders among adults were first diagnosed before they were 14 years old.

Researchers have identified many factors within the family, schools, and community that can increase or decrease the risk of children developing mental, emotional, and behavioral problems. In addition, several interventions have shown promise in reducing the risk of such problems becoming well-established disorders.

Poverty, a parent’s mental illness, child abuse and neglect, divorce and separation, and poor parenting are among the family circumstances that put children at greater risk of developing disorders. Academic failure, bullying, and violence are among the risk factors children may encounter in their schools and communities.

New perspectives on the development of the brain that researchers began reporting more than a decade ago also have implications for preventing the onset of mental, emotional, and behavioral problems. They found that not only does a great deal of brain development occur very early in childhood, it also is greatly influenced by experience and environment.

The National Academies report recognizes this, stating that the body of evidence shows that mental, emotional, and behavioral disorders are developmental; that the earliest years of life are the most opportune times to affect change; and that children develop in the context of their families, schools, and communities—environments that cannot be ignored if their risks of developing disorders are to be reduced.

The report also argues that supporting the development of children requires coordination and collaboration across systems—such as public health, health care, and education—in order to more effectively support and finance preventive interventions on multiple levels.

Effective prevention of mental, emotional, and behavioral problems first and foremost requires a way of thinking that goes beyond the traditional disease model of waiting until a disorder occurs and then providing treatment.

It also challenges everyone from researchers and educators to practitioners and policymakers to develop and adapt to approaches designed to prevent these disorders from becoming stubborn, debilitating problems for children and young adults.

Broadly shifting to a prevention model that focuses on early childhood as an advantageous period for addressing mental, emotional, and behavioral problems will likely not be easy or quick. Such a change affects everything from government reimbursement structures to the training of those who work with children but are not familiar with the development of mental, emotional, and behavioral disorders. In fact, many professionals in fields ranging from health care to childcare fall into that category.

For example, said Firth, “when you talk to speech therapists, they know that a lot of the children they serve for a speech problem also have emotional problems. But they haven’t been trained to address it as part of speech therapy. Their training is limited, even though they know that it is an important dimension of the children they are serving—that the child’s speech is not independent of the child’s socio-emotional development. Many people in early childhood don’t even have that level of training.”

The good news is that prevention-based approaches have steadily gained support in recent years as effective ways to improve a range of child outcomes, particularly in Allegheny County.

The county, for example, is home to one of the nation’s most successful networks of family support centers, which take a collaborative, prevention-based approach to improving the well-being of children by strengthening families and communities. The Pittsburgh Public Schools is one of several districts that uses Promoting Alternative Thinking Strategies, a curriculum for helping educators promote development of self-control, emotional awareness, and problem-solving skills among children. The Allegheny County Maternal and Child Depression Initiative organized a partnership to build a more cohesive, seamless system for diagnosing and treating women for depression that includes health insurance companies, Pennsylvania Department of Public Welfare, Medicaid managed care organizations, OCD and local general health and mental health providers, service agencies, community organizations, and consumers. Left untreated, a mother’s depression increases the risk of her child developing behavioral problems, experiencing academic difficulties, and other poor outcomes.

Across Pennsylvania, early childhood education has gained considerable support in recent years across Pennsylvania as a way to prevent school failure. Initiatives such as Pre-K Counts and Keystone STARS, for example, have improved the quality of early learning environments, making it more likely that children will be prepared to succeed in school.

From a national perspective, much work remains to be done to more broadly and effectively address mental, emotional, and behavioral disorders through prevention, according to the National Academies report.

The report calls on the White House to create a federal entity to lead the implementation of evidence-based prevention approaches and fund state and local efforts to put those approaches into practice. It also urges continuing research across disciplines to better understand what prevention approaches work and how to best implement them, and suggests that the National Institutes of Health develop a 10-year plan to study ways to promote mental health and prevent mental, emotional, and behavioral disorders in children.

“There is a substantial gap between what is known about preventing mental, emotional, and behavioral disorders and what is actually being done,” said Kenneth E. Warner, dean of the University of Michigan School of Public Health, who chaired the committee that oversaw the National Academies report. “It is no longer accurate to argue that these disorders can never be prevented. Many can. The nation is well positioned to equip young people with the skills and habits needed to live healthy, happy, and productive lives in caring relationships. But we need to develop the systems to deliver effective prevention programs to a far wider group of children and adolescents.”

National Research Council and Institute of Medicine. (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. O’Connell, M.E., Boat, T., & Warner, K.E. Ed. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.

A brief for researchers of the above report is available online at: http://www.bocyf.org/prevention_policymakers_brief.pdf