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Realizing Population-Level Improvements for All Children’s Cognitive, Affective, and Behavioral Health

2016; Elsevier BV; Volume: 51; Issue: 4 Linguagem: Inglês

10.1016/j.amepre.2016.07.017

1873-2607

C. Hendricks Brown, William R. Beardslee,

Health Policy Implementation Science

The strategy of using prevention as a first line of behavioral health care, particularly for children, is well accepted on scientific, economic, and social justice grounds. It just has not been made as a cornerstone of health in the U.S. Currently, the systems to promote children's mental health and well-being; prevent substance abuse; and provide enabling, stimulating, and nurturing environments are not functioning in ways that our children and families need. This is evidenced by high rates of depression, youth homicide and suicide, and substance misuse, as well as the existence of major health disparities. The disparities that minorities and poor communities often experience, in both health and health service, often have roots in the communities they reside, where violence is present; housing and education are substandard; stigma and discrimination are prevalent; and health, education, housing, job training, and other social service systems fail to address their critical needs. However, major elements of a behavioral prevention system do exist and can be integrated to provide a major shift toward improving children's behavioral health and well-being. This special issue focuses on such system-level innovations in research, practice, and policy that can promote children's cognitive, affective, and behavioral health. Several unique factors are coming together that hold much promise on taking prevention programs to scale. Firstly, there is a strong scientific knowledge base, in terms of what prevention programs work, for whom, for how long, and under what conditions. Evidence from randomized trials and other non-randomized but rigorous designs have identified numerous prevention programs and practices that improve children's behavioral health, often extending across multiple stages of life. Secondly, a science of implementation is being built that has begun to identify robust strategies for scaling up these interventions and adapting them to local conditions. Thirdly, there is increased investment in prevention and promotion as communities, non-governmental and governmental organizations, and the private sector begin to recognize the full magnitude of behavioral health problems and the costs of delayed action or inaction. Fourthly, the Patient Protection and Affordable Care Act and the Mental Health Parity and Addiction Equity Act greatly expanded behavioral health insurance and the right to services to an estimated 63 million Americans,1Beronio K. Glied S. Frank R. How the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care.J Behav Health Serv Res. 2014; 41: 410-428https://doi.org/10.1007/s11414-014-9412-0Crossref PubMed Scopus (139) Google Scholar, 2Frank R.G. Beronio K. Glied S.A. Behavioral health parity and the Affordable Care Act.J Soc Work Disabil Rehabil. 2014; 13: 31-43https://doi.org/10.1080/1536710X.2013.870512Crossref PubMed Scopus (48) Google Scholar much of this through primary care. Finally, there is renewed interest in local communities; states, territories, and tribes; and federal agencies in working together to find creative ways to enhance prevention, with behavioral preventive services ranging from early home visiting3Health Resources and Services Administration. Demonstrating Improvement in the Maternal, Infant, and Early Childhood Home Visiting Program: A Report to Congress. 2016. http://mchb.hrsa.gov/programs/homevisiting/buckets/reportcongress.pdf. Accesssed June 27, 2016.Google Scholar to HIV prevention programs4Neumann M.S. Sogolow E.D. Replicating effective programs: HIV/AIDS prevention technology transfer.AIDS Educ Prev. 2000; 12: 35-48PubMed Google Scholar to community-based programs to prevent drug abuse5Office of National Drug Control PolicyDrug-Free Communities Support Program: 2014 National Evaluation Report. Office of National Drug Control Policy, Washington, DC2015Google Scholar and prevent youth suicide,6Garraza L.G. Walrath C. Goldston D.B. Reid H. McKeon R. Effect of the Garrett Lee Smith memorial suicide prevention program on suicide attempts among youths.JAMA Psychiatry. 2015; 72: 1143-1149https://doi.org/10.1001/jamapsychiatry.2015.1933Crossref PubMed Scopus (51) Google Scholar, 7Walrath C. Garraza L.G. Reid H. Goldston D.B. McKeon R. Impact of the Garrett Lee Smith youth suicide prevention program on suicide mortality.Am J Public Health. 2015; 105: 986-993https://doi.org/10.2105/AJPH.2014.302496Crossref PubMed Scopus (60) Google Scholar and to interventions for those recently experiencing a first episode psychosis.8Azrin S.T. Goldstein A.B. Heinssen R.K. Early intervention for psychosis: the recovery after an initial schizophrenia episode project.Psychiatr Ann. 2015; 45: 548-553https://doi.org/10.3928/00485713-20151103-05Crossref Scopus (10) Google Scholar, 9Kane J.M. Robinson D.G. Schooler N.R. et al.Comprehensive versus usual community care for first-episode psychosis: 2-year outcomes from the NIMH RAISE Early Treatment Program.Am J Psychiatry. 2015; 173: 362-372https://doi.org/10.1176/appi.ajp.2015.15050632Crossref PubMed Scopus (463) Google Scholar There has also been a deep recognition in the medical field of the behavioral, social, and economic factors that impact children's health.10Boat T.F. Improving lifetime health by promoting behavioral health in children.JAMA. 2015; 313: 1509-1510https://doi.org/10.1001/jama.2015.2977Crossref PubMed Scopus (11) Google Scholar The Board on Children, Youth, and Families, through the Division of Behavioral and Social Sciences and Education and the Health and Medicine Division within the National Academies of Sciences, Engineering, and Medicine (the Academies) has established a Forum on Promoting Children's Cognitive, Affective, and Behavioral Health, supported by 16 sponsoring organizations.11National Academies of Sciences Engineering and Medicine. Forum on Promoting Children's Cognitive, Affective, and Behavioral Health. www.nationalacademies.org/hmd/Activities/Children/ChildrensHealthForum.aspx. Accessed June 30, 2016.Google Scholar The papers in this special issue derive from workshops and other activities hosted by this forum over the last 2 years. This forum sprung from work on an earlier National Research Council/Institute of Medicine (now the Health and Medicine Division) consensus study12Institute of Medicine, National Research CouncilPreventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The National Academies Press, Washington, DC2009https://doi.org/10.17226/12480Crossref Scopus (1092) Google Scholar that documented the extensive scientific progress and value of mental health promotion and prevention for children and youth. Although this consensus statement focused on progress, it also documented major gaps in understanding how to enhance the adoption of evidence-based prevention programs, how to deliver them with fidelity in diverse service delivery systems and communities, how to scale these programs up, and how to sustain them over time. The forum's aims are to inform a forward-looking agenda for building a stronger research and practice base around the development and implementation of programs, practices, and policies to promote all children's cognitive, affective, and behavioral health, including those with disabilities. The forum recognizes the important principles of social justice and health equity as cornerstones for the work, and embraces a broad public health approach. The forum also identifies what implementation successes and challenges have been learned by communities, decision makers, practitioners, and researchers, and how these lessons can improve the health and well-being of all children. The papers included in this issue provide a range of approaches to prevention and wider-scale dissemination and implementation coming from forum presentations and collaborations. They represent new approaches to improving availability, access, and reliable use of a continuum of evidence-based interventions to meet the needs of all children and are appropriate for the systems that deliver such programs and the communities where they live. Also critical to these visionary perspectives are the building and sustainment of partnerships that allow diverse communities, service delivery systems, and researchers to align their work and complement one another's strengths. Among the major research achievements in prevention of behavioral problems are those programs focusing on improving parenting.12Institute of Medicine, National Research CouncilPreventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The National Academies Press, Washington, DC2009https://doi.org/10.17226/12480Crossref Scopus (1092) Google Scholar, 13Mihalic S.F. Elliott D.S. Evidence-based programs registry: blueprints for healthy youth development.Eval Program Plann. 2015; 48: 124-131https://doi.org/10.1016/j.evalprogplan.2014.08.004Crossref PubMed Scopus (75) Google Scholar, 14Blueprints for Healthy Youth Development. Blueprints programs. www.blueprintsprograms.com/programs. Accessed June 27, 2016.Google Scholar, 15Substance Abuse and Mental Health Services Administration. National Registry of Effective Programs and Practices. www.nrepp.samhsa.gov. Accessed June 27, 2016.Google Scholar As Leslie and colleagues16Leslie L.K. Mehus C.J. Hawkins J.D. et al.Primary health care: potential home for family-focused preventive interventions.Am J Prev Med. 2016; 51: S106-S118Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar note in their paper, many of these parent education/skill-building programs have been shown to be effective and economically beneficial, but few, other than those involving birthing classes, have been implemented widely. These authors propose that delivery of such parenting programs through primary care would greatly expand their use by reducing stigma and by offering quality programs in or through a professional and trusted health system. Furthermore, these programs could be reimbursed fully by most insurance programs if it was determined by the U.S. Preventive Services Task Force (Task Force) that their "net benefit" is moderate or substantial to a degree of high certainty. Pathways to such a determination are presented. The second paper by Kemper et al.17Kemper A.R. Mabry-Hernandez I.R. Grossman D.C. U.S. Preventive Services Task Force approach to child cognitive and behavioral health.Am J Prev Med. 2016; 51: S119-S123Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar describes the process by which the Task Force makes its decisions with regard to child cognitive and behavioral health. An important function of this body, beyond grading of evidence, is to point out gaps in the existing knowledge base. Thus, screening for autism spectrum disorder for those aged younger than 3 years received an "insufficient" rating in 2016, not as a statement against conducting such screening but as a call for more research. Though the Task Force has evaluated only a small fraction of behavioral interventions for children, and made recommendations about screening for depression and other conditions, there is a critical need to coordinate the timing of such activities. A full review that occurs before sufficient research has been conducted will likely end in an insufficient recommendation, although a "ripe" research field will "spoil" if it has to wait in a long line for review. Such coordination is critical for bringing prevention programs to scale and delivering effective programs to America's families. Chambers' and Norton's18Chambers D.A. Norton W.E. The adaptome: advancing the science of intervention adaptation.Am J Prev Med. 2016; 51 (http://dx.doi.org/10/1016/j.amepre.2016.05.011): S124-S131Abstract Full Text Full Text PDF PubMed Scopus (298) Google Scholar paper on the Adaptome begins by noting that the traditional translational pipeline—which moves from program development and efficacy to effectiveness testing, followed by implementation research and practice19Brown CH, Curran G, Palinkas LA, et al. An overview of research and evaluation designs for dissemination and implementation. Annu Rev Public Health. In press.Google Scholar—needs to be informed by more practice-based implementation.20Green L.W. Making research relevant: if it is an evidence-based practice, where's the practice-based evidence?.Fam Pract. 2008; 25: i20-i24https://doi.org/10.1093/fampra/cmn055Crossref PubMed Scopus (426) Google Scholar This will create an ever-expanding evidence base and assure that knowledge about implementation need not wait until an intervention is fully tested.21Mohr D.C. Schueller S.M. Riley W.T. et al.Trials of intervention principles: evaluation methods for evolving behavioral intervention technologies.J Med Internet Res. 2015; 17: e166https://doi.org/10.2196/jmir.4391Crossref PubMed Scopus (126) Google Scholar This paper calls for a "full science of intervention adaptation," which would need a "multidisciplinary team of researchers, practitioners, implementers, and consumers" to provide and assess data on program adaptation in real-world settings. Such a perspective would advance health equity for both minorities and other populations that are currently underserved or ineffectively served by existing programs. Rith-Najarian and colleagues22Rith-Najarian L.R. Daleiden E.L. Chorpita B.F. Evidence-based decision-making in youth mental health prevention.Am J Prev Med. 2016; 51 (http://dx.doi.org/10.1016/j.amepre.2016.05.018): S132-S139Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar discuss the translation of successful approaches to knowledge translation and decision making for designing, implementing, and evaluating interventions in mental health treatment to the prevention field. In their view, evidence-based decision making about programs takes advantage of all available knowledge and resources and using them to "direct goals and actions with more certainty" through distillation of common practice elements and use of value of information and other approaches to address uncertainties. Such an approach can lead to new preventive interventions that address the needs of specific populations as well as incorporate key elements of evidence-based programs. Like the other papers in this issue, this vision for prevention depends on a high degree of collaboration and interdisciplinary activities among potential users, developers, researchers, and organizations to coordinate general and local knowledge into action. Next are two papers that address wide-scale federal initiatives to deliver evidence-based prevention programs administered by this country's two major public health agencies, the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration. Collins and Sapiano23Collins C.B. Sapiano T.N. Lessons learned from dissemination of evidence-based interventions for HIV prevention.Am J Prev Med. 2016; 51: S140-S147Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar discuss lessons learned from the Diffusion of Effective Behavioral Interventions Project for HIV prevention that was conducted by CDC's Division of HIV/AIDS Prevention. Working in close partnership with the original program developers, this project has prepared implementation packages and conducted trainings for 29 such programs to more than 11,000 agencies. They point out lessons learned from this project that can inform other large-scale dissemination strategies. One fundamental lesson was the recognition that, despite the rich evidence base, there was a gap between the needs of policymakers and practitioners (e.g., programs focusing on men who have sex with men) and what research had been done. By focusing on such gaps, CDC was able to direct research efforts to fill them. Secondly, adaptations were continually required to integrate new findings (e.g., biomedical advances to prevention and treatment) and community needs and values. The paper by Harding et al.24Harding F.M. Hingson R.W. Klitzner M. et al.Underage drinking: a review of trends and prevention strategies.Am J Prev Med. 2016; 51: S148-S157Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar presents a national response to prevent underage drinking in the U.S. through the Sober Truth on Preventing Underage Drinking Act, directed by the Substance Abuse and Mental Health Services Administration's Center for Substance Abuse Prevention. This program builds on existing Drug-Free Community coalitions funded through the White House and trained by the Community Anti-Drug Coalitions of America to implement comprehensive, community, policy, and enforcement-based approaches to reduce underage drinking and binge drinking. Such approaches can be enhanced when combined with alcohol screening and referral of adolescents, a promising approach that still needs more research. Also, a key challenge for the field is supporting the sustainment of prevention programs that are directed by community organizations, especially after federal funding ends. The final paper in this special issue, written by Cruden and colleagues,25Cruden G. Kelleher K. Kellam S. Brown C.H. Increasing the delivery of preventive health services in public education.Am J Prev Med. 2016; 51: S158-S167Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar discusses an integrated partnership between three mostly siloed institutions: public health, primary care, and public education. Although integration of the first two has been identified as critical for improving health in general, the general and specific prevention needs of children's behavioral health need to involve schools as well, as this offers unique opportunities to address the diverse needs of nearly all children from age 5 years throughout adolescence. Though prevention programs cannot take away from the major mission of schools to educate and socialize children, the commonalities between behavioral health and cognitive health, defined therein by "the neurological and reasoning, memory, language, and attention capacity of youth," are abundantly clear and preventive interventions can improve youth outcomes in education, behavioral health, as well as physical health. This paper pays special attention to the formation of partnerships based on mutual self-interest and their sustainment through financing by public, non-profit hospitals, and private partnerships. Broad themes have emerged from these papers as well as presentations and discussion in the forum. First, there is a need to take a systems approach, aligned with public health, that focuses on improving the health of populations as well as addressing health disparities. Second, there is a need to engage all levels of community (diverse individuals, service delivery and research organizations, and political leaders) in collaborative decision making, with shared accountability for actions and change. These partnerships must engage diversity, express political will to promote children's health, and be responsible for ongoing change and vigilant to sustain both health outcomes and the infrastructure to support such outcomes. A workforce is also needed of researchers, practitioners, and community leaders who have competencies in community engagement and organization, as well as systems change. Fundamental to this vision is the need to build research and engineering of prevention systems that address the needs of communities along with the integration of multiple sectors of service delivery systems. Major activities by the Academies are being advanced to support this broad mission of moving effective prevention programs and improving economic, educational, and social service systems in communities in order to address social determinants of children's health. Workshops have focused on scaling up family-based preventive interventions26Institute of Medicine, National Research CouncilStrategies for Scaling Effective Family-Focused Preventive Interventions to Promote Children's Cognitive, Affective, and Behavioral Health: Workshop Summary. The National Academies Press, Washington, DC2014https://doi.org/10.17226/18808Crossref Scopus (4) Google Scholar; harvesting the scientific investment in prevention through implementation in mental health, schools, child welfare, and juvenile justice27Institute of Medicine, National Research CouncilHarvesting the Scientific Investment in Prevention Science to Promote Children's Cognitive, Affective, and Behavioral Health: Workshop Summary. The National Academies Press, Washington, DC2015https://doi.org/10.17226/18964Crossref Google Scholar; using measurement systems to monitor the implementation of evidence-based programs28Institute of Medicine, National Research CouncilInnovations in Design and Utilization of Measurement Systems to Promote Children's Cognitive, Affective, and Behavioral Health: Workshop Summary. The National Academies Press, Washington, DC2015https://doi.org/10.17226/21661Crossref Google Scholar; addressing the unique opportunities to integrate prevention into health care29National Academies of Sciences Engineering and MedicineOpportunities to Promote Children's Behavioral Health: Health Care Reform and Beyond: Workshop Summary. The National Academies Press, Washington, DC2015https://doi.org/10.17226/21795Crossref Google Scholar; facilitating depression prevention and treatment into pediatric care30National Academies of Sciences Engineering and MedicineIdentifying Opportunities for Prevention and Intervention in the Youth Depression Cascade: Workshop in Brief. The National Academies Press, Washington, DC2016https://doi.org/10.17226/23397Crossref Scopus (1) Google Scholar; and promoting cognitive, affective, and behavioral health in children who have complex medical or educational needs.30National Academies of Sciences Engineering and MedicineIdentifying Opportunities for Prevention and Intervention in the Youth Depression Cascade: Workshop in Brief. The National Academies Press, Washington, DC2016https://doi.org/10.17226/23397Crossref Scopus (1) Google Scholar Perspective papers have addressed the power of prevention,31Hawkins J.D. Jenson J.M. Catalano R. et al.Unleashing the Power of Prevention: Discussion Paper. Institute of Medicine and National Research Council, Washington, DC2015https://nam.edu/perspectives-2015-unleashing-the-power-of-prevention/Google Scholar, 32Hawkins J.D. Jenson J.M. Catalano R. et al.A Challenge to Unleash the Power of Prevention: Commentary. Institute of Medicine and National Research Council, Washington, DC2015https://nam.edu/perspectives-2015-a-challenge-to-unleash-the-power-of-prevention/Google Scholar healthcare reform to promote children's mental and behavioral health,33McCabe M.A. Health Care Reform as a Vehicle For Promoting Children's Mental and Behavioral Health: Discussion Paper. Institute of Medicine and National Research Council, Washington, DC2015https://nam.edu/perspective-2015-health-care-reform-as-a-vehicle-for-promoting-childrens-mental-and-behavioral-health/Google Scholar and family-focused interventions for children with disabilities.34Jones R.M. Perou R. Shih A. Unique Opportunities and Challenges in Implementing Family-Focused Interventions for Children with Developmental Disorders: Discussion Paper. Institute of Medicine and National Research Council, Washington, DC2014https://nam.edu/perspectives-2014-unique-opportunities-and-challenges-in-implementing-family-focused-interventions-for-children-with-developmental-disorders/Google Scholar Along with these opportunities afforded by the Patient Protection and Affordable Care Act, there is an additional need to provide prevention and wellness funds for strengthening communities to promote healthy development through the integration of systems and elimination of separate carve outs. A major approach would be to extend local and state programs focused on "Health in All Policies" to include "Healthy Development in All Policies," as this would facilitate developing approaches for financing and funding services that are sustainable. Tying into this focus would be the inclusion of metrics on children's and adolescents' behavioral health in all ongoing community and agency needs assessments. Publication of this article was supported by Members of the Forum on Promoting Children's Cognitive, Affective, and Behavioral Health. The authors gratefully acknowledge the financial contributions of the National Academies of Sciences, Engineering, and Medicine's Forum on Promoting Children's Cognitive, Affective, and Behavioral Health to this special issue. Forum members and presenters at forum-sponsored workshops provided insights and perspectives that are highlighted in this commentary, and we have borrowed heavily from these in this commentary. We also thank the forum's activity directors, Morgan Ford and Wendy Keenan, for providing exceptional support around all activities leading to this special issue, and special thanks to Sarah Tracey for her support on managing the papers in this special issue. We thank the National Institute on Drug Abuse for their support on grant number P30-DA027828 (Brown, Principal Investigator) and the Sydney R. Baer, Jr. Foundation (Beardslee, Principal Investigator). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Drug Abuse (NIDA) or the Sydney R. Baer, Jr. Foundation, the organizations and members of the Forum, or the National Academies of Sciences, Engineering, and Medicine. Brown received salary support from NIDA research grant number P30-DA027828. Beardslee received salary support from the Sydney R. Baer, Jr. Foundation. Brown and Beardslee serve as co-chairs (unfunded) of the National Academies of Sciences, Engineering, and Medicine's Forum on Promoting Children's Cognitive, Affective, and Behavioral Health, which provided funding for this special issue and administrative assistance in producing these papers. The Academies, NIDA, nor the Baer Foundation were involved in writing or reviewing these papers. No financial disclosures were reported by the authors of this paper.