IACAPAP Textbook of Child and Adolescent Mental Health

INTRODUCTION

Chapter

A.14

HEALTH PROMOTION AND
PREVENTION IN CHILD AND
ADOLESCENT MENTAL HEALTH
Kerry O’Loughlin, Robert R. Althoff & James J. Hudziak

Kerry O’Loughlin BS
Graduate Student Research
Assistant, University ofVermont, College of Medicine,
US
Conflict of interest: nonereported

Robert R. Althoff MD, PhD

Associate Professor of
Psychiatry, Psychology and
Pediatrics & Director, Divisionof Behavioral Genetics,
Vermont Center for Children,
Youth & Families, University ofVermont College of Medicine,
Burlinton, US
Photo: Vermont Center for Children, Youth, and Families. Reproduced with permission

Conflict of interest: none
disclosedThis publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2017. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: O’Loughlin K, Althoff RR, Hudziak JJ. Health promotion and prevention in child and adolescent mental
health. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child andAdolescent Psychiatry and Allied Professions 2017.

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IACAPAP Textbook of Child and Adolescent Mental HealthThe perfect storm for positioning the field of child and adolescent mental
health to the forefront of health care reform is upon us. If we embrace the powerand scope of health promotion and illness prevention, our field will become
central to the care and wellbeing of all children and families. Child and adolescent
psychiatrists are the only physicians trained to understand the emotional andbehavioral correlates of the structure and function of the developing brain. No
other field combines classic medical training with an understanding of brain andbehavior development from birth to age 24, the age span that defines the children
and families we serve. Over the past two decades multiple domains in medical
research have matured to the point that child and adolescent psychiatry is perfectly
positioned to execute a paradigm shift in how our field is defined and practiced.
The change agents include rapid advances in the understanding of genetics(Rijlaarsdam et al, 2014), epigenetics (Weder et al, 2014), and structural(Ducharme et al, 2011) and functional (Stringaris et al, 2015) neuroimaging
studies of large populations of children across development (Verhulst & Tiemeier,2015). This research allows our field to understand the unique vulnerabilities
and opportunities that occur during the epoch of brain development. With the
explosion of interest in, and evidence from the Adverse Childhood Experiences(ACEs) study, it is now clear that the same factors that place children at risk foranxiety, depression, and substance abuse also contribute to similarly elevated risk
for obesity, diabetes, and hypertension (and many other general medical problems)(Felitti et al, 1998).

James J Hudziak MD
Professor, Departmentsof Psychiatry, Medicine& Pediatrics; Thomas
M Achenbach Chairin Developmental
Psychopathology; Director,
Vermont Center for Children,
Youth & Families; Directorof Child and Adolescent
Psychiatry, Fletcher Allen
Health Care, University ofVermont, College of Medicine;
Professor, Erasmus University,
Sophia Children’s Hospital,
Rotterdam, The Netherlands;
Adjunct Professor, Child
Psychiatry, Washington
University, St Louis, MO
Conflict of interest: nonereported
A different version of thischapter is published in
Lewis’s Child and Adolescent
Psychiatry: A Comprehensive
Textbook, fifth edition (2017)

These data allow our field to rightly claim a special role in addressing andpreventing the factors that precede the most common and costly of all medical
illnesses, not just psychiatric illness. Another major advance exists in the area of
health promotion. Cardiologists would never define themselves as physicians who
only care for patients’ with end stage heart disease, rather cardiology is defined
as a field that also has developed heart health promotion and illness prevention
programs (e.g., through diet and exercise). This has led the rest of medicine toappreciate the importance of promoting cardiac health in all humans. Childand adolescent psychiatry should and can follow the same method. Modern
neuroscience gives child and adolescent psychiatrists the opportunity to design
brain health promotion programs from pregnancy to adulthood.
Epidemiologic research in psychiatry and child psychiatry has moved awayfrom dependence on categorical models of diagnoses as embodied by DSM-V(American Psychiatric Association, 2013) and into quantitative diagnostic
procedures. It has become increasingly obvious that all children (indeed all
humans) experience sadness, anxiety, inattention, risk taking, rule breaking,and quirkiness—thus redefining the target populations for child and adolescent
psychiatry away from serving only children who meet criteria for largely inadequate
diagnoses to all children. In other words, all of us carry symptoms of emotionaland behavioral vulnerability and a new child psychiatry can devote itself to theservice of all children.
To conclude, the era of family-based medical care is upon us. The realizationthat treating children as if they exist in a vacuum is no longer tenable in our field orin any other field in medicine. However, we can take the lead in developing new
programatic approaches. For almost as long as our field has existed, the argument

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IACAPAP Textbook of Child and Adolescent Mental Healthfor family based care has been made; however, with new research, we now havethe evidence to confidently move the argument forward that the best way to help
children or adolescents achieve wellness is to help their families become well.
These advances, taken together, invite child and adolescent mental healthpractitioners to operate under the following postulates: the environment influences
genomic health, which in turn influences the structure and function of the brain,
which in turn influences a child’s thoughts, feelings, and behaviors. Given that all
health begins with emotional and behavioral health, the path to wellness begins
with creating healthy environments for all children and families.

The environment influences
genomic health, which inturn influences the structureand function of the brain,
which in turn influences achild’s thoughts, feelings,
and behaviors.

With this in mind child psychiatry can enter the epoch of accountable careand health care reform with the following responsibility: we must design, test, andimplement health promotion programs aimed at building healthy brains from birth
to adulthood. We must design, test, and implement illness prevention programs
aimed at helping those at risk from developing psychopathologies and medical
morbidities (that are very difficult to treat in adulthood). When we intervene
we should do so in a family-based manner with the knowledge that the best way
to serve a child is to serve a child’s family. If child psychiatry accepts this charge,
we essentially place ourselves at the center of health care reform. Our profession
already contributes to the health and wellbeing of children in school settings, inpediatric and community settings, as well as in our clinics and hospitals. Armedwith new evidence we can contribute strategies to promote health in all children, toprevent the development of illness in many, and to intervene in a more evidenced
family based way for those who struggle with emotional and behavioral illness.
In this chapter we provide child and adolescent mental health practitioners
with the evidence for illness prevention and health promotion and describe one
model of family based intervention that already is in place in schools, pediatricsettings, and clinics in the US and elsewhere (Hudziak & Bartels, 2008; Mrazek& Mrazek, 2007).

HISTORY OF PREVENTION
Over the last 50 years, the terminology surrounding prevention has
undergone a number of revisions (Mrazek & Mrazek, 2007) summarized in Table
A.14.1. In 1964, in an effort to establish a consistent nomenclature, the field of
psychiatry adopted a series of definitions to describe efforts toward prevention. In
Caplan’s Principles of Prevention Psychiatry, prevention was subdivided into three
categories: primary, secondary and tertiary (Caplan, 1964). Primary prevention
was defined as “an intervention designed to decrease the number of new casesof a disorder or illness;” secondary prevention was defined as “an intervention
designed to lower the rate of established cases of a disorder or illness,” and tertiary
prevention was defined as “an intervention designed to decrease the amount of
disability associated with an existing illness” (Mrazek & Mrazek, 2007).
In 1983, Gordon proposed a prevention classification system based on thecosts and benefits of delivering an intervention to a targeted population (Gordon,
1983; O’Connell et al, 2009). Gordon’s taxonomy distinguished between universal,
selective, and indicated prevention. In this framework, universal prevention
referred to strategies for an entire population. Selective prevention referred
to strategies that targeted a subpopulation deemed to be at risk for a disorder.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table A.14.1 Conceptualizations of prevention interventions
TYPES OF PREVENTION (Caplan, 1964)
Primary

Aims at decreasing the number of new cases of a disorder

SecondarySeeks to lower the rate of established cases of a disorder or illness in the population(prevalence)

Tertiary

Endeavours to decrease the amount of disability associated with an existing illness

LEVELS OF PREVENTION PROPOSED BY GORDON (1987)
Universal

Targets everyone in the eligible population

Selective

Focuses only on individuals whose risk of becoming ill is above average (e.g., have specific risk
factors)

Indicated

Targets individuals who are identified as being at high risk for the future development of adiseaseLEVELS OF PREVENTIVE INTERVENTIONS RECOMMENDED BY THE INSTITUTE OF
MEDICINE (Mrazek & Haggerty, 1994)
Universal

Targets the general public or a whole population group that has not been identified on the basisof individual risk. The intervention is desirable for everyone

Selective

Focuses on individuals or a subgroup of the population whose risk of developing mental
disorders is significantly higher than average. The risk may be imminent or it may be a lifetime
risk

Indicated

Targets high risk individuals who are identified as having minimal but detectable signs or
symptoms of a mental disorder but who do not meet currently full criteria for a diagnosis

Finally, indicated prevention referred to strategies that targeted individuals who
were asymptomatic, but deemed, based on an individualized assessment, to be atincreased risk (Gordon, 1983).
In 1994, a US Institute of Medicine (IOM) report—Reducing Risk
for Mental Disorders: Frontiers for Preventive Intervention Research (Mrazek &Haggerty, 1994)—proposed a continuum of care beginning with prevention,and including both treatment and maintenance (see Figure A.14.1). Prevention
referred to interventions implemented prior to a patient receiving a diagnosis;
treatment referred to interventions provided to individuals suffering from adisorder; and maintenance referred to long-term interventions designed to reduce
rates of relapse and disability and to promote rehabilitation among individuals
with chronic mental illness (Mrazek & Haggerty, 1994; Mrazek & Mrazek, 2007 ).
Approximating the model proposed by Gordon, the 1994 IOM committee divided
what was formally referred to as primary prevention into indicated, selective, anduniversal preventive interventions. In this model, distinction among indicated,
selective, and universal interventions was based on the population being targeted.
Universal interventions were designed to serve an entire population, selective

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure A.14.1 Range of interventions available to deal with mental health problems according to
the US Institute of Medicine model (Mrazek & Haggerty, 1994)

interventions served individuals at heightened risk, and indicated interventions
served populations manifesting early symptoms of a disorder (Mrazek & Haggerty,1994). This conceptualization differed from Gordon’s model because indicatedpreventive interventions targeted individuals with prodromal symptoms (rather
than individuals who were at-risk, yet asymptomatic). Within the context ofsuch definitions, the IOM’s 1994 report also proposed that as risk increases theintensity of the intervention and the costs associated with that intervention would
also increase (Springer & Phillips, 2006).
While the IOM model provides a useful framework for conceptualizing
the nature and degree of risk faced by vulnerable populations, it is important tonote that there is often significant overlap and inter-relatedness among vulnerable
populations (Springer & Phillips, 2006). Indeed, individuals manifesting the early
symptoms of psychopathology (i.e., an indicated population), are often a subset ofindividuals at increased risk (i.e., a selective population). As such, the distinction
between selective and indicated preventive interventions is often nebulous. Beyond
the broad definitions provided by the IOM in1994 there are no explicit criteria forwhether a preventive intervention be classified as selective or indicated (Springer& Phillips, 2006).

HEALTH PROMOTION
In 2009, a National Academy of Sciences (NAS) committee largely concurredwith the continuum (i.e., including prevention, treatment, and maintenance)laid out in the IOM’s 1994 report. However, the NAS’ report suggested that inaddition to prevention, treatment, and maintenance, the conceptualization should
be broadened to include the promotion of mental health. Citing the World HealthOrganization’s (1986) proclamation that health is more than merely the absenceof disease, the NAS committee defined mental, emotional, and behavioral healthpromotion as “efforts to enhance individuals’ ability to achieve developmentally

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IACAPAP Textbook of Child and Adolescent Mental Healthappropriate tasks (developmental competence) and a positive sense of self-esteem,
mastery, wellbeing, and social inclusion, and to strengthen their ability to copewith adversity” (Blueprints for Healthy Youth Development). In the NAS report,
health promotion was characterized as focusing on wellbeing rather than on theprevention of illness. While drawing this distinction, however, the report also
highlighted the considerable overlap between prevention and health promotion,
stating that: “both [prevention and health promotion] focus on changing common
influences on the development of children and adolescents in order to aid themin functioning well in meeting life’s tasks and challenges and remaining free of
cognitive, emotional, and behavioral problems that would impair their functioning”(O’Connell et al, 2009).

ESTABLISHED PREVENTIVE INTERVENTIONSBoth the IOM and NAS have acknowledged on a conceptual level theimportance of prevention. However, research within child and adolescent mental
health has lagged behind such conceptual advances. To date there are a limited
number of preventive interventions and even fewer with a strong empirical-base.
Therefore, selecting an evidence-based preventive intervention can prove difficultfor physicians, mental health care providers, communities, schools, and parents
alike.
There are, however, a number of registries which evaluate and rank preventive
interventions based on the strength of their empirical evidence, one such registry is
the Blueprints for Healthy Youth Development Program. Funded by the Annie
E Casey Foundation, the Blueprints for Healthy Youth Development Programprovides a freely available registry of evidence-based preventive interventions. Since
its inception, the Blueprints program has reviewed more than 1,400 preventive
interventions. During this time, only 14% of programs have met the registry’s
minimum inclusion criteria, and less than 1% have been designated as “model”
programs.
To be designated as a “model program”, a preventive intervention must have:
1. A minimum of either two high quality randomized control trials or
one high quality randomized control trial and one high quality quasiexperimental evaluation
2. A positive intervention impact sustained for 12 months after the
program intervention ends; and3. A significant impact, intervention specificity, and dissemination
readiness.

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Click on the image to accessthe Blueprints for Healthy
Youth Development Programwebsite. This website
provides a freely available
registry of evidence-based
preventive interventions
that have been evaluatedaccording to the research
evidence backing them.
More than 1,400 preventive
interventions have been
evaluated thus far.

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IACAPAP Textbook of Child and Adolescent Mental Health

To be a “model plus program” an intervention must meet the above model
criteria and have undergone independent replication.
In the interest of providing an overview of the existent preventive
interventions with the largest evidence-base, each of the programs receiving
the “model” or “model plus” designation from the Blueprints registry is briefly
described below, more details for these and other programs can be found in theBlueprints website. Based on the definitions established in the IOM’s 1994 report,
the programs reviewed below have been categorized as universal or selective/
indicated preventive interventions.

UNIVERSAL PREVENTIVE INTERVENTIONSThe Life Skill Training Program (LST)The LST is a classroom-based program designed to prevent adolescentsfrom engaging in alcohol use, drug use, and violent behavior. The LST is designed
to teach students self-management skills, social skills, and drug-resistance skills,
and has been associated with short- and long- term reductions in tobacco use,alcohol use, illicit-substance use, poly-substance abuse, violence, and delinquency.
In addition, at 6- and 10- years follow up, the LST has been associated with
reductions in risky driving (Griffin et al, 2004), and HIV risk behaviors (Griffin
et al, 2006).

The Positive Action ProgramThis is a school-based program designed to enhance social-emotional
learning and positive behavior in elementary and middle school students (aged
5 to 13 years). The classroom component teaches self-management skills as well
as strategies to increase the use of positive social behavior. The Positive Action
Program also includes a school-wide component designed to reinforce the classroom
intervention. The Positive Action Program has been associated with a reduction
in suspensions and absenteeism, in substance use, violence, and sexual activity,
increased rates of socio-emotional development, higher life satisfaction, reduced
rates of depression and anxiety, reduced rates of unhealthy food consumption, as
well as overall improvements in school quality (Washburn et al, 2011).

The Promoting Alternative Thinking Strategies (PATHS)
The (PATHS) program is school-based also and is designed to reduce
aggression and promote emotional and social competencies in children grades K-6(5 to 11 year olds). The PATHS intervention targets five domains: self-control,
emotional understanding, positive self-esteem, relationships, and interpersonal
problem-solving skills. This intervention attempts to involve parents byincorporating home activity assignments and providing parents with information.
PATHS has been associated with lower rates of conduct and externalizing problems,
lower internalizing scores, better emotion recognition abilities, reductions indelinquency, and higher proficiency scores in reading, writing, and maths (Riggs
et al, 2006; Schonfeld et al, 2015).

Project Toward No Drug Abuse (TND)
Project TND is a drug prevention program for high school students who are
at risk for substance use and violent behavior. Project TND is designed to enhance

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IACAPAP Textbook of Child and Adolescent Mental Healthself-control, communication, resource acquisition, and decision-making. Project
TND has been implemented as a universal preventive intervention in general
populations as well as a selective preventive intervention among high-risk students.
Project TND has been associated with reductions in cigarette and marijuana use,
“hard” substance use, weapon carrying, and victimization, with reductions in“hard” drug use being sustained for up to five years post-intervention (Sussman etal, 2002; Sun et al, 2006).

SELECTIVE OR INDICATED PREVENTIVEINTERVENTIONS
Nurse Family Partnership (NFP)
The NFP is a maternal health program which provides home visitation
for first-time, low-income mothers by maternal and child health nurses. Theintervention is designed to improve pregnancy outcomes, improve infant health,promote infant development, and improve the mother’s life-course trajectory. In
particular, during pregnancy, the NFP is designed to eliminate cigarette-, alcohol-,and drug-use, and encourage exercise, and sound personal hygiene habits (Oldset al, 1997). The NFP also aims to prepare mothers for labor, delivery, and childcare. Among mothers, the NFP program has been associated with reductions inunintended pregnancies, domestic violence, and increased rates of employment.
Among children, the NFP has been associated with reductions in hospitalization
for injury and illness, accelerated language development, reduced rates of behavior
problems at age 6, and reduced rates of arrests, internalizing disorders, andsubstance use at age 12 (Olds et al, 2014).

New Beginnings
The New Beginnings program is an intervention for divorced motherswith children ranging in age from 5 to 18. This is a parent-driven intervention
designed to help mothers engage in effective child behavior management
strategies, enhance the quality of mother-child interactions, and reduce children’s
exposure to interparental conflict. Among children, the New Beginnings program

Click on the image to accessthe Australian Nurse Family
Partnership.

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IACAPAP Textbook of Child and Adolescent Mental Healthhas been associated with decreases in internalizing, externalizing, and aggressive
behaviors (Wolchik et al, 1993; 2000). With respect to family dynamics, the New
Beginnings intervention has been associated with improvements in the use ofeffective discipline strategies, parent-child communication, and positive routines(Wolchik et al, 1993).

Treatment Foster Care Oregon (TFCO)The TFCO is a 6-month intervention for adolescents with a history ofantisocial behavior, emotional disturbance, and delinquency. Foster families
from the community are recruited and trained to provide adolescents with clear
and consistent limits, appropriate consequences, and positive reinforcement for
appropriate behavior. In so doing, the TFCO system also provides adolescentswith a mentoring adult and separation from delinquent peer group. The TFCO
uses a behavior modification approach where adolescents can accrue points forappropriate behavior and can gain increased levels of independence over time. The
TFCO also includes individual and family therapy and emphasizes that adolescentsdevelop interpersonal skills and participate in social and recreational activities.
The TFCO program is associated with a reduction in days spent incarcerated, in
tobacco and marijuana use, in violent offenses and, among females, in the odds of
becoming pregnant (Kerr et al, 2009).

Multisystemic Therapy (MST)MST is a family and community based intervention designed to improveantisocial behavior patterns in adolescent juvenile offenders. MST works acrossmultiple settings (i.e., home, school and community) to increase prosocial behavior
and decrease antisocial behavior. MST has been associated with decreased rates of
re-arrest, recidivism, incarceration, psychopathology, and substance use, as well as
increased rates of community service (Fain et al, 2014).

Multisystemic Therapy-Problem Sexual Behavior (MST-PSB)
Similar to the broader MST, MST-PSB focuses on the family, school,peer, and community systems in which an adolescent is embedded in order toreduce antisocial behavior. However, MST-PSB concentrates specifically on thedimensions of the youth’s environment that are related to problematic sexual
behavior. MST-PSB strives to increase each adolescent’s friendships and age
appropriate sexual experiences, and works with adolescents to increase perspectivetaking abilities and maladaptive beliefs and attitudes, particularly around sexual
offending. MST-PSB is associated with reductions in re-arrests for sexual andnon-sexual crimes (Borduin et al, 1990), parent and child psychiatric symptoms,
youth behavior problems, as well as improvement in peer relationships, family
functioning, and academic performance (Borduin et al, 2009).

The Blues Program
The Blues Program is a group cognitive-behavioral intervention foradolescents with prodromal symptoms of depression. The program seeks toprovide social support and helps adolescents restructure maladaptive thoughts,
develop plans to respond to future stressors, and participate in pleasant activities.
The Blues Program has been associated with reductions in depressive symptoms
immediately following the intervention (Rohde et al, 2014), 6 months postintervention (Stice et al, 2008), and one and two years post intervention (Stice etPrevention

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IACAPAP Textbook of Child and Adolescent Mental Healthal, 2010). Adolescents participating in the Blues Program also report reductions
in substance abuse immediately following the intervention and 6-months postintervention.

The Body ProjectThis is a 4-week group intervention designed for high school and collegeaged females with disordered eating. The Body Project engages participants in body
acceptance exercises and teaches strategies to avoid peer pressure. Post-intervention,
the Body Project is associated with decreases in thin ideal internalization (theextent to which an ideally slim female body is internalized), body dissatisfaction,negative affect, risk for obesity onset, symptoms of bulimia, and disordered eating(Stice et al, 2006). Many of these effects are maintained for three years.

Brief Alcohol Screening and Intervention for College Students(BASICS)
BASICS consists of a two-session intervention designed for individuals aged
18-24 who are at-risk for alcohol use disorders. BASICS seeks to help college-aged
students better understand the risks associated with drinking, enhance motivation
to change, develop skills to drink moderately, and ultimately make betteralcohol-use related decisions. College-aged students who participate in BASICS
demonstrated reduced rates of drinking and problem behaviors at 2- and 4- years
follow up (Baer et al, 2001). Among first year college students, BASICS has been
associated with lower levels of peak blood alcohol concentration and reductions in
the number of drinks consumed during the weekend.

Functional Family Therapy (FFT)This is a family-based intervention targeting delinquent adolescents and theirfamilies. FFT is designed to enhance parenting skills, youth compliance, family
communication and supportiveness, while decreasing negativity and dysfunctional
behavioral patterns. FFT is associated with reductions in recidivism, youth
internalizing and externalizing symptoms, substance use, as well as enhanced
family interaction patterns (Alexander & Parsons, (1973).

Parent-Management Training-Oregon Model (PMTO)
The PMTO is a group-based parent training intervention for the parents ofchildren ranging in age from early childhood to late adolescence. PMTO is designed

Click on the image to accessthe BASICS program websiteof the University of Michigan.

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IACAPAP Textbook of Child and Adolescent Mental Healthto enhance effective family management skills and thereby reduce antisocial andproblematic behavior in children. Research suggests that PMTO is associated with
reductions in coercive parenting, noncompliance, and negative reinforcement, andincreases in effective and positive parenting (Forgatch & DeGarmo, 1999). Amongchildren, PMTO is associated with reduced rates of oppositional defiant disorder,
aggression, internalizing disorders, and externalizing disorders. Nine years postintervention, PMTO is associated with decreases in teacher-rated delinquency
and arrest rates (Martinez & Forgatch, 2001; DeGarmo et al, 2004; Forgatch &DeGarmo, 2007; Forgatch et al, 2009).

SUMMARY OF EXISTING PREVENTIVEINTERVENTIONS
Irrespective of the population being targeted, the goal of preventive
interventions is to reduce the influence of established causal risk factors, augment
the availability and/or influence of known protective factors, and reduce thelikelihood that children will develop (or progress towards) psychopathology.
Cutting across the many contexts (e.g., individual, peer, family, school,community) in which a given child or adolescent is embedded, and utilizing avariety of therapeutic modalities (e.g., school-based, individual, group, family)
the preventive interventions outlined above can exert a significant influence on avariety of known risk and protective factors. Broadly speaking, these interventions
can be broken down into those involving the child and those involving the family,summarized in Table A.14.2.

ESTABLISHED AND EMERGING MODALITIES FORPREVENTION AND HEALTH PROMOTION
Clearly, at both the child and family level, preventive interventions havethe capacity to shore up protective factors and reduce risk factors. Given theprominence of family level variables in the preventive interventions outlined, andgiven the known genetic and environmental contributions to every developmental
psychopathology that has been studied, we view parental emotional/behavioral
well being and positive parenting as critical components of prevention and healthpromotion in children and adolescents. As such we will briefly review the researchsurrounding parental psychopathology and positive parenting. Then, keeping in
mind that emotional/behavioral health is a key component of overall health, we
present the emerging science supporting the health-promoting capacities of music,
mindfulness, nutrition, and exercise.

Established Modalities
Parental Psychopathology
The presence of a parent with psychopathology serves as a nonspecificrisk factor for multiple forms of psychopathology in the offspring includinginternalizing, externalizing, and substance use disorders (Rutter & Quinton,
1984; Beardslee et al, 1998; McLaughlin et al, 2012). The risk associated withparental psychopathology is conferred via genetic and environmental mechanisms(Boomsma et al, 2005; Althoff et al, 2006; Van Grootheest et al, 2007; Hudziak& Bartels, 2008). Yet, even when the influence of prominent environmental risk

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Table A.14.2 Risk and protective factors that can be modified bypreventive interventions

FAMILY-BASED

CHILD-BASEDRISK FACTORSPROTECTIVE FACTORS

•
•
•
•
•
•
•
•
•

Low school commitment
Body-image concerns
Aggressive behavior
Physical violence
Poor academic performance
Substance use
Attitudes toward drug use
Attitudes toward antisocial behavior
Interaction with antisocial peers

•
•
•
•
•
•
•

Coping skills
Problem-solving skills,
Perceived risk of drug use
Social interaction skills
Drug refusal skills
Prosocial involvement
Interaction with prosocial peers
Academic self-efficacy

•
•
•
•
•
•

Family violence
Parental mental health difficulties
Poor family management
Neglectful parenting
Lack of prenatal careHousehold adults involved in
antisocial behavior
Low socioeconomic status
Maternal substance use during
pregnancy
Parental unemployment
Unplanned pregnancy
Parent stress

•
•
•
•

Clear standards for behavior
Non-violent discipline
Good attachment to parents
Parental social support

•
•
•
•
•

factors (e.g., childhood adversity, low SES) is controlled for, a child who has aparent with psychopathology is still 1.5-8 times more likely to develop emotional/
behavioral problems (Bijl et al, 2002; Wansink et al, 2016).
Research also suggests that when parental psychopathology is treated therisk conferred to offspring is reduced. For example, children who have a parent
with a depressive disorder are four times more likely to develop psychopathology(Beardslee et al, 1998). When maternal depression is treated, children show
reduced rates of psychopathology, improved academic performance, and enhanced
overall functioning (Weissman et al, 2006; Gunlicks & Weissman, 2008). The
reduction in child problem behaviors associated with the successful treatment ofmaternal depression are maintained at 6 months, one, and four years follow up(Gunlicks & Weissman, 2008). Thus, treating parental psychopathology, canpromote mental health in the offspring.
Parent Training
Along with parental psychopathology, the parenting practices employedwithin the home exert a considerable influence on the environment in which achild’s development occurs. It has been suggested that a potential mechanism
through which some forms of parental psychopathology confer risk for childpsychopathology is via parenting behavior. Indeed, research suggests that parental
psychopathology can compromise effective parenting behavior (Harvey et al,

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IACAPAP Textbook of Child and Adolescent Mental Health2011), and that a reciprocal relationship exists between parenting behavior andchild psychopathology (Burke et al, 2008).
Parent training programs are designed to provide parents with parenting
strategies to increase their child’s compliance and prosocial behavior, and reduce
their child’s oppositional and aggressive behavior (see Chapter A.12 of the
Textbook for a detailed description of parenting programs). Some of the best
researched programs are: Helping the Noncompliant Child (McMahon & Forehand,2015), The Incredible Years (Webster-Stratton, 2006), Parent Management Training(Kazdin, 2005), and Triple-P (Sanders et al, 2000).
It is well established that parent training programs are an effective treatment
for children struggling with clinically significant disruptive and externalizing
behavior. However parent training is also effective in children and adolescentswithout clinically significant psychopathology. Even among otherwise healthy
toddlers, the preventative use of parent training has been associated with reductions
in externalizing and disruptive behavior over a five-year period (Dishion et al,2014). Therefore, effective and positive parenting can both treat and prevent thedevelopment of child psychopathology.

Emerging Modalities
Beyond the established role of parental psychopathology and parent training,
there are a number of health-promoting modalities that have an emerging evidencebase and are established enough that we believe they can begin to be implemented
with little risk in standard practice. These are mindfulness training, nutrition,
exercise, and music training.
Mindfulness
As it applies to modern Western health care, mindfulness has been definedas the ability to disengage from one’s beliefs, thoughts, and actions, and attend
to moment-to-moment experience in a non judgmental manner (Ludwig &Kabat-Zinn, 2008). It has been suggested that such a state can be fostered using
a variety of techniques (e.g., mindfulness meditation, mindful breathing, mindful
movement, and short meditations during the course of the day) (Allen et al, 2006)(see Appendix A.14.1).
Over the last 35 years, mindfulness has been incorporated into a numberof psychosocial interventions including: dialectical behavior therapy, acceptanceand commitment therapy, mindfulness-based stress reduction (MBSR), andmindfulness-based cognitive therapy, with research suggesting that suchinterventions can be effective in treating a range of conditions including borderline
personality disorder, anxiety disorders, mood disorders, eating disorders, highstress levels, and chronic pain.
Beyond the application of mindfulness to clinical populations, researchalso suggests that mindfulness may be a helpful strategy for individuals who do
not evidence clinically significant levels of psychopathology. Among otherwise
healthy adults, MBSR is associated with increases in mindfulness that temporally
precede reductions in negative affect (Snippe et al, 2015). Similarly, among college
students without clinical levels of psychopathology, MBSR is associated with adecrease in symptoms (Allen et al, 2006).

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IACAPAP Textbook of Child and Adolescent Mental HealthA body of work suggests that mindfulness may be particularly beneficial
for women during pregnancy. Both randomized controlled (Vieten & Astin,
2008; Guardino et al, 2014) and uncontrolled studies suggest that mindfulness
training for pregnant women is associated with reductions in physical pain, stress,
depression, and anxiety. Maternal stress and anxiety during pregnancy have been
associated with infant’s being born preterm and of low birth weight, as well as poorer
cognitive, emotional, and developmental outcomes in infancy and childhood (Vanden Bergh et al, 2005; Guardino et al, 2014). Thus, some have argued that helping
mothers achieve emotional/behavioral wellness during pregnancy may be a means
to prevent the development of negative outcomes in children.
In addition to work suggesting that mindfulness may be an effective
intervention for adults, research also suggests that it may be an effective prevention
and treatment strategy in children. Meta-analyses suggest that mindfulness
interventions have a small to moderate effect on emotional/behavioral symptoms
in general populations of children and adolescents and a slightly larger effectin clinical populations (Zenner et al, 2014; Zoogman et al, 2015). However,while mindfulness interventions may effectively promote resilience in universal
populations of children and treat psychopathology in children with mental
disorders, more randomized control trials exploring their affect in children areneeded.
Nutrition
It has long been established that a nutritious and well-balanced diet is a criticalcomponent of overall wellness. Research suggests that a healthy diet contributes toenhanced cardiovascular health, reduced rates of cancer, and longevity. Recently,
research has begun to suggest that there is an association between nutrition andmental health.
In both children and adults, diet quality has been shown to influencelearning, memory, and mood (Gomez-Pinilla, 2008; Zainuddin & Thuret, 2012).
In adolescents, internalizing and externalizing disorders are positively associatedwith increased consumption of fast food, red meat, and sugar, and negatively
associated with increased consumption of fresh fruit and vegetables (Oddy etal, 2009). Prospective longitudinal studies suggest that, among adolescents, dietquality may be causally related to mental health (Jacka et al, 2011). In adults,
diets of low quality are associated with increased rates of anxiety and depression,
reduction in molecular substrates involved in cognitive processing, and increased
risk for neurological disorders.
In addition to overall diet quality, a variety of nutritional deficiencies
has been associated with emotional/behavioral illness. Cross sectional work inadults suggests that low serum cholesterol is associated with antisocial, violent,and self-injurious behavior. Cross sectional studies with children suggests thatiron and zinc deficiencies are associated with externalizing behavior and ADHD,
respectively (Liu et al, 2015). Longitudinal research with children suggests that
zinc, iron, and vitamin B deficiencies during early childhood are associated withexternalizing disorders during adolescence (Liu et al, 2015). In children, diets low
in omega-3 fatty acids have been associated with hyperactivity, learning disorders,and behavioral problems, and recent interventional studies suggest that omega-3
fatty acid supplementation results in reductions in externalizing behaviors (LiuPrevention

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IACAPAP Textbook of Child and Adolescent Mental HealthEngaging in physicalexercise is associatedwith a decreased risk
for a host of general
medical conditions. It
has also been suggested
that exercise may be apreventive intervention for
psychopathology.

et al, 2015). It has been hypothesized that the association between nutritional
deficiencies and mental health may be mediated by epigenetic changes and alteredbrain structure and function (Liu et al, 2015).
ExerciseEngaging in physical exercise is associated with a decreased risk for a hostof general medical conditions including obesity, diabetes, and cardiovasculardisease. It has also been suggested that physical exercise may be a viable preventive
intervention and treatment for psychopathology.
Most research exploring the effects of exercise on clinically significant
psychopathology in adults has examined the influence of exercise on depression andanxiety (Rebar et al, 2015). Among adults with depression, some meta-analyses
suggest that exercise has a moderate to strong effect on depressive symptoms whileothers suggest that it has a minimal effect. According to another report (Physical
Activity Guidelines Advisory Committee, 2008), in otherwise healthy adults,
correlational studies suggest that individuals who are regularly physically active
report fewer symptoms of anxiety and depression and have lower risk of developing
a depressive disorder and anxiety disorder. While such work does not elucidate thedirection of these effects, a recent meta-analysis using data from 400 randomized
trials and 14,000 participants suggests that, among adults with non clinical levelsof anxiety and depression, exercise results in a medium but significant reduction ofdepressive symptoms, and a small but significant reduction of symptoms of anxiety(Rebar et al, 2015). Such work suggests that exercise may be a viable preventive
intervention among individuals with subclinical symptomatology.
Research has also explored the relationship between physical activity
and psychopathology in children and adolescents, suggesting that physicalactivity appears to have a small but beneficial effect on symptoms of anxiety
and depression, a large effect on self-esteem, and to be associated with improved
cognitive performance, classroom behavior, and academic achievement (Biddle &Asare, 2011). In addition, aerobic exercise programs in children have a moderate
to large effect on the symptoms of ADHD (Cerrillo-Urbina et al, 2015).
Music
Recently there has been an explosion of interest in the neurophysiological,
cognitive, and behavioral correlates of playing music. While music is an emerging

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IACAPAP Textbook of Child and Adolescent Mental Healthhealth promoting modality, research to date suggests that playing a musicalinstrument is associated with alterations in brain structure and function, enhanced
cognitive functioning, and improvements in academic performance. A long standing
body of work with children and adults suggests that, relative to amateur musicians
and non-musicians, practiced musicians show structural and functional differencesin various regions of the brain. In adults, practiced musicians display structuraldifferences in the primary sensorimotor cortex, superior premotor cortex, superiorparietal cortex, primary auditory cortex, cerebellum, inferior frontal gyrus, andlateral temporal lobe (Gaser & Schlaug, 2003). Research among adult professionalmusicians suggests a positive association between music training during childhood,adolescence, and adulthood and white matter tract development. Similarly, crosssectional studies with children suggest that, relative to children who do not playmusical instruments, children who play an instrument show increased grey matterin the sensorimotor cortex and occipital lobe, increased activation of the temporal
lobe during rhythmic and melodic discrimination tasks (Schlaug et al, 2005), anddistinct patterns of cortical thickness maturation in the dorsolateral prefrontal
cortex (Hudziak et al, 2014).
Given the cross-sectional and correlational nature of much of this research,such work cannot conclude whether structural and functional brain differences
are a consequence of increased musical practice or whether it reflects underlying
neuroanatomical differences that predated exposure to music. Recently, however,research with children has begun to suggest that musical training may indeed becausally related to both changes in cognition and changes in brain structure andfunction. Relative to a control group of children matched on age, verbal IQ, andSES, children who played an instrument for one year showed significantly greater
fine motor and visual discrimination skills (Schlaug et al, 2005). Relative to acontrol group, children who engaged in musical training for 15 months exhibited
improvements in motor and auditory skills, as well as structural changes in theright precentral gyrus, the corpus callosum, the right primary auditory region, thepericingulate, and the left middle occipital lobe (Hyde et al, 2009).
Music training in children may be causally related to changes in cognition.
Relative to a control group who did not receive musical instruction, 5 year oldchildren who received 20 minutes of twice weekly music instruction showed
improvements in spatial temporal tasks at 4 and 8 months (Rauscher & Zupan,
2000). Another study with low-income 4 and 5 year olds also suggests that, relative
to a control group, children receiving 75 minutes daily of music instruction for
30 weeks showed improvements in visuospatial reasoning (Bilhartz et al, 2000).
Despite this evidence the majority of school children do not play a musicalinstrument regularly. There are, however, two emerging preventive intervention
programs that use music training as a means to offset risk: El Sistema (Cuesta et al,2007) and The Harmony Project.
El Sistema originated in Caracas, Venezuela, and is a music education
program serving more than 500,000 Venezulean children. More recently, El
Sistema has been implemented in the US and currently more than 2 million at risk
American children partake in the El Sistema curriculum. The El Sistema program isbelieved to have resulted in a 20% reduction in school dropout, a 22% increase inparticipation in community activities, and a 28% increase in employment amongchildren who participate (Cuesta et al, 2007).

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IACAPAP Textbook of Child and Adolescent Mental Health

The Harmony Project is a
non-for-profit organization
based in the US thatprovides music instructionand ensemble performanceexperiences for low-income
youth.

The Harmony Project is a non-for-profit organization based in the US
that provides music instruction and ensemble performance experiences for
low-income youth. The Harmony Project is currently being implemented inseventeen sites in Los Angeles as well as seven other major cities across the US.
Students participating in the Harmony Project receive several hours of musicalinstruction per week. Children enrolled show significant gains in neural andauditory processing mechanisms linked with reading and language skills. In
addition, participation in the Harmony Project is associated with parent-rated
improvements in mood, health, grades, and behaviors. Relative to schools that
do not participate, participating schools show improvements in graduation rates
and college attendance. While music training is an integral part of the Harmony
Project, the project also utilizes a mentorship model and thereby offsets risk bycapitalizing on other known protective factors (e.g., social support) (Kraus et al,2014; 2014b).

THE VERMONT FAMILY-BASED APPROACH (VFBA)
Examining these emerging domains of prevention and health promotion,
it becomes evident that few, if any, of the evidence based preventive interventions
described above take into account the emerging literature from neuroscience,
psychology, and genetics to incorporate treating family psychopathology, positiveparenting, mindfulness, nutrition, music training, and exercise into one cohesive
approach. With that in mind, we present here a new clinical and public healthparadigm: the Vermont Family-Based Approach.

Click on the image to viewa short video clip describing
the Vermont family-based
approach (4:42).

The VFBA was developed by James J Hudziak MD at the VermontCenter for Children, Youth, and Families and is designed to integrate researchon developmental psychopathology into a family-based therapeutic intervention.
The VFBA is conceptualized as a means to both treat and prevent the developmentof emotional-behavioral illnesses in children, and is based on a few central tenets:
1. Emotional-behavioral health is the cornerstone of all health
2. All health is familial
3. Health promotion, prevention, and intervention should take into
account the emerging evidence on music, mindfulness, nutrition, andexercise.

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IACAPAP Textbook of Child and Adolescent Mental Health•

VFBA Tenet #1: Emotional-behavioral health is the foundation of allhealth.
This arises from the emerging literature on the role of psychopathology
in nearly every other medical discipline. Nowhere is this more evident thanin the role of adverse childhood experiences on a wide range of child andadult pathologies, from obesity and diabetes to sexually transmitted diseases(Felitti et al, 1998). This literature demonstrates that the way that experiences
are managed during childhood does not just affect later mood and behavior
but also other medical conditions seemingly unrelated to psychopathology.
Further, attending to patients’ emotional/behavioral health allows for a more
adequate treatment of multiple other conditions including heart disease,cancer, and diabetes, again demonstrating that the cornerstone of healthpromotion, prevention, and intervention of medical conditions is attending
to emotional/behavioral health.

•

VFBA Tenet #2: All health is familial.
In the VFBA paradigm, the treatment of parental psychopathology
and the utilization of parent training are viewed as means to both treat andprevent the development of child psychopathology. Given that parental
psychopathology is a known risk factor for child psychopathology, the VFBA
seeks to improve child and adolescent mental health by providing mental
health care to the children and their parents. The VFBA is based on thepremise that addressing parents’ clinical and subclinical mental health needs
will help to prevent and facilitate the treatment of existing emotional andbehavioral conditions in the children.
Along with parental psychopathology, the parenting practices
employed within the home exert an influence on the environment in which achild’s development occurs. As such, in addition to addressing both children’sand parents’ mental health needs, the VFBA utilizes evidence-based parent
training strategies to improve parent-child dynamics. Thus, within the
VFBA paradigm, parenting training is conceptualized as a treatment to help
families who are struggling with child psychopathology, as well as a means
to bolster parenting skills and prevent the development of psychopathology
among children who are otherwise healthy.

•

VFBA Tenet #3: Health promotion, prevention, and intervention shouldtake into account the emerging evidence on mindfulness, nutrition,
exercise, and music.
The VFBA promotes family wellness by encouraging the entire family
to engage in health promoting activities including mindfulness training,
healthy eating, exercise, and music training. In this way, the components of
the VFBA serve as both effective treatments for children and parents withpsychopathology, as well as selective, indicated, and universal preventive
interventions for families who are well.

Click on the image to viewa lecture by James Hudziak
MD describing in somedetail the rationale behind
the Vermont family based
approach to behavioral
disorders (1:28:07).

Mindfulness
Given the growing body of evidence suggesting mindfulness’ utility as
both a treatment and a preventive intervention, there is reason to be optimistic
about the role of mindfulness in mental health. However, while there are somerandomized controlled studies on the effects of mindfulness-based interventions

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IACAPAP Textbook of Child and Adolescent Mental Health(e.g., mindfulness-based CBT) many studies on its effects are compromised bysmall sample sizes, lack of control groups, lack of randomization, and lack of dataon treatment compliance (Burke et al, 2008). In particular, more well-controlled
studies are needed on the effect of mindfulness in children. Nonetheless, thestate of the evidence is such that within the VFBA paradigm, mindfulness isconceptualized as a health promoting activity. As such, parents and children who
are well, at-risk, and struggling with psychopathology are encouraged to engage inmindfulness practices.
Nutrition
Given the body of research implicating overall diet quality and specificnutritional deficiencies in general medical as well as emotional-behavioral disorders,the VFBA paradigm conceptualizes a healthy, balanced diet as a treatment strategy
among families who are struggling with emotional/behavioral illness, as well as apreventive intervention among those who are well.
Exercise
While it cannot be concluded with certainty that the relationship between
exercise and mental health is direct and causal, it seems reasonable to hypothesizethat the reductive effects of physical activity on psychopathology “cannot be
explained by a single mechanism acting in isolation; rather the effects are most likely
due to the contribution of several mechanisms (e.g., mood, feelings of mastery,self-efficacy) and neurophysiological (hippocampal neurogenesis, hypothalamic
pituitary adrenal axis regulation” (Zainuddin & Thuret, 2012). Given the available
research, the VFBA paradigm conceptualizes exercise as a viable treatment andpreventive strategy, and encourages parents and children to engage in physicalactivity through structured exercise programs, often using fitness coaching, andpositive reinforcement.
Music
Because of the body of research suggesting that music training is associatedwith changes in brain structure and function, and the findings from school-based
programs such as El Sistema and Harmony Project that music training is associatedwith improvements in cognition as well as improved academic performance, theVFBA strongly encourages a musical component for the entire family. Althougha randomized controlled trial using clinical samples has yet to establish a direct
relationship between music training and a reduction in psychopathology, theavailable evidence suggesting music training’s utility as a preventive strategy as
well as music training’s impact on neuroanatomy has led to its incorporation in
the VFBA. Within the VFBA paradigm, children who are well and children who
are struggling with emotional/behavioral problems, along with their families, areencouraged to play a musical instrument.
Demonstrating the effectiveness of the VFBA
While the effectiveness of each of the components of the VFBA have been
demonstrated to a larger or lesser extent, the VFBA in its entirety has not beenformally tested. A randomized clinical trial of the VFBA paradigm is currently
underway. This trial is projected to include 120 to 160 families with a childbetween the ages of 3 and 6. Families enrolled in treatment will be partnered witha family wellness coach who will help them implement a health and wellness plan

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IACAPAP Textbook of Child and Adolescent Mental Healthbased on the results of a family-wide assessment. This assessment will include
standardized measures of each family members’ emotional/behavioral health, aswell as assessment of the health promoting activities in which they engage. Eachfamily’s health and wellness plan will be tailored to their specific needs, but will
rely on the fundamental principles of the VFBA: family-wide mental health care,positive parenting strategies, mindfulness, nutrition, exercise, and music training.

SUMMARY
Child and adolescent psychiatry is perfectly positioned to play a critical rolein health promotion, illness prevention, and family-based intervention. We are
the only medical professionals who understand the impact of the environment on
the genome (epigenome), the structure and function of the developing brain, andrelated thoughts, feelings, and behaviors (symptoms). We can prescribe wellness
to all children (e.g., mindfulness, exercise, nutrition, sleep, music etc.) regardless ofwhether or not they are at risk or already struggling with emotional or behavioral
problems. We can assist in prevention by ensuring that all parents have accessto parent training, and promote the idea that treating parental emotional andbehavioral problems is a far more powerful tool than ignoring such problems. We
can become the field that recognizes the importance of prescribing social supports
and education around the difficult task of raising healthy children and, when wetreat children who are in the grip of psychopathology, we should do so in a familybased manner that includes concomitant health promotion and illness prevention
perscriptions. Basic developmental neuroscience and genomic evidence exists(the Adverse Childhood Experiences study provides a perfect platform for national
attention) and accountable care is an invitation to fund a reform that will placechild and adolescent psychiatry at the center of health care reform.

Parents play a criticalrole in the optimal
development and wellbeing of their children.
While this is true for allparents and all children, it
is particularly relevant forthe caregivers of children
with developmental
disorders. To respond to
this need, WHO developed
the WHO Parent Skills
Training Package forcaregivers of children with
developmental disorders.
Fifty four experienced
health professionals from18 countries attended acapacity-building workshop
on the WHO Parent Skills
Training Package hosted by
WHO in April 2015.

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IACAPAP Textbook of Child and Adolescent Mental Health

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