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Preventing Violent Behaviors -- Mental Health Interventions

In a recent report requested by CMHS, Greenberg, Domitrovich, & Bumbarger (1999) at the Prevention Research Center for the Promotion of Human Development at Pennsylvania State University, reviewed the effectiveness of prevention programs for preventing mental disorders in school-aged children. They write as follows:

In the last decade, prevention has moved into the forefront and has become a priority for many Federal agencies in terms of policy, practice, and research... There is growing concern in our country as increasing numbers of children and adolescents are having difficulty managing the challenges of development. Between 12% and 22% of America’s youth under age 18 are in need of mental health services and an estimated 7.5 million children and adolescents suffer from one or more mental disorders. In addition to the personal suffering experienced by children with emotional or behavioral problems and their families, mental health disorders also have a tremendous cost to society. According to the National Advisory Mental Health Council, in 1990 mental illness cost an estimated $74.9 billion dollars (p.1)

To reduce levels of childhood mental illness, preventive interventions need to be provided prior to the development of significant symptomatology. According to Greenberg and his colleagues, "developmental theory provides a powerful framework for organizing and building the field" of prevention of mental illness (p.2) They continue as follows:

It is apparent that developmental risk factors are not disorder-specific, but may relate instead to a variety of maladaptive outcomes... Recent findings in behavioral epidemiology indicate that mental health problems, social problems, and health risk

behaviors often co-occur as an organized pattern of adolescent risk behaviors.... Because risk factors may predict multiple outcomes and there is great overlap among problem behaviors, prevention efforts that focus on risk reduction of interacting risk factors may have direct effects on diverse outcomes (Pp.4-5).

Researchers have determined that preventive interventions are best directed at risk and protective factors rather than at categorical problems behaviors. With this perspective, it is both feasible and cost-effective to target multiple negative outcomes in the context of a coordinated set of programs.

Among the primary concerns of the CMHS initiative are disruptive behavior disorders (i.e., oppositional defiant disorder, conduct disorder, and attention deficit hyperactivity disorder) which, according to Greenberg and his colleagues, are among the most prevalent and stable child psychiatric disorders. It is typically these children who are at risk of violence as perpetrators and victims. Greenberg and his colleagues note that, "compared to other mental health disorders, a substantial amount of basic research has been conducted in the last twenty years on the disruptive behavior disorders. We now have sophisticated developmental models of how these problems develop and an awareness of the risk and protective factors involved in their initiation and maintenance" (pp. 18-19). They continue as follows:

Forty percent of children diagnosed with conduct disorder between the ages of 8 and 12 still have the disorder four years later. Many of the most serious and costly adult mental health outcomes and societal problems (e.g., delinquency, substance use, and antisocial personality disorder) have their origins in early conduct problems.... Conduct disorder is one of the most difficult conditions to remediate because the disorder is often supported in multiple contexts, the risk factors associated with it tend to cluster together and are related in complex ways, and each risk factor tends to set the stage for increase risk in the next phases of development" (p.18).

Greenberg notes that "treatment for conduct disorder has demonstrated positive short term outcomes but there is less evidence for long term success. There are a number of reasons why treatment with younger children, or more ideally, prevention at, or prior to, symptom onset is more likely to be effective" (p.18).

In light of the difficulties involved in treating conduct disorders, it makes sense to consider an array of universal prevention programs targeting school-aged children. One such program is Promoting Alternative Thinking Strategies (PATHS) which is an elementary school-based program to promote social/emotional competencies through cognitive skill building. With a heavy emphasis on teaching students to identify, understand, and self regulate their emotions, PATHS also adds components for parents and school context beyond the classroom to increase generalizability of the students newly acquired skills. In a randomized controlled trial, PATHS produced significant improvements in social problem solving and understanding emotions (p.12).

Other effective prevention programs are ecologically-focused interventions that attempt to address contextual variables in the child’s home or school as a means to prevent or reduce psychopathology or negative outcomes. The Effective Black Parenting Program places a primary emphasis on the importance of family ecology by focusing on parental skill building and family management. The program, developed specifically for African American families with elementary-aged children, teaches cognitive-behavioral parenting skills with an emphasis on promoting a culturally relevant style of child self-discipline. In a controlled study of a relatively small sample of families form Los Angeles, the researchers found reductions in withdrawn and hyperactive behaviors and delinquency for boys (p.15).

Recently a consortium of prevention researchers have developed FAST TRACK, a school-wide program that integrates universal, selective, and indicated models of prevention. The universal intervention includes teacher consultation in the use of a series of grade level versions of the PATHS Curriculum throughout the elementary years. The targeted intervention package includes a series of interventions that involves the family, the child, the school, the peer groups, and the community. Results of the first three years indicate there are significant reductions in special education referrals at school, and in aggression both at home and at school, for the targeted children. FAST TRACK is predicated on a long-term model that assumes that prevention of anti-social behavior will be achieved by building competencies and protective factors in the child, family, school, and community. The initial results provide strong support for improved social and academic development (p.25).

Greenberg concludes that:

While there has been important and meaningful progress in prevention research with children, families and schools during the past two decades, there has been little focus on what factors in the child, e.g., gender, ethnicity or environment might moderate the impact of the intervention. It is necessary to know more regarding for whom specific programs are most likely to be effective. With few exceptions, there has been little exploration of how the quality of implementation affects outcome. There is a need for greater attention to both the measurement of dosage as well as the quality and fidelity of the intervention delivery (p. 32).

We now know that programs which truly make a difference in children’s lives must be intensive, comprehensive, and of significant duration. Moreover, they must be aimed at changing not just individuals, but the families, institutions, and environments in which individuals live. Regarding the current status of research, Greenberg and his colleagues conclude:

In spite of substantial gains in prevention research during the last two decades, it is important to acknowledge that considerable progress is needed to affect more tangibly the lives of America’s children and families. Only a small group of researchers has designed and evaluated multi-year, multi-component programs that target multiple mental health outcomes. Few successful efficacy trials have been replicated by independent investigators, and there have been even fewer attempts to evaluate the implementation process and impact of widely disseminated program models. In summary, although a solid scientific base is being created, the most important knowledge regarding preventive interventions will come from the next generation of prevention researchers (Greenberg, Domitrovich, & Bumbarger, p. 33).

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