U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

www.samhsa.gov

Promotion and Prevention

in Mental Health:

Strengthening Parenting and 

Enhancing Child Resilience

Promotion and Prevention in Mental Health

Promotion and Prevention 

in Mental Health:

Report to Congress

Requested in 

Senate Report 109-103

and

Conference Report 109-337

Submitted by the

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Mental Health Services

Strengthening Parenting and 

Enhancing Child Resilience
Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or 

copied without permission from SAMHSA. Citation of the source is appreciated. However, 

this publication may not be reproduced or distributed for a fee without the specific, written 

authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Copies of Publication 

This publication may be accessed electronically through the following Internet World Wide 

Web connection: www.samhsa.gov. For additional free copies of this document, please call 

SAMHSA’s Health Information Network (SHIN) at 1-800-SAMHSA-7, or 1-800-487-4889 

(TDD).

Recommended Citation

Substance Abuse and Mental Health Services Administration, Center for Mental Health 

Services (2007). Promotion and Prevention In Mental Health: Strengthening Parenting and 

Enhancing Child Resilience, DHHS Publication No.CMHS-SVP-0175. Rockville, MD.

Originating Office

SAMHSA, Center for Mental Health Services

1 Choke Cherry Road, Room 6-1089

Rockville, MD 20857

DHHS Publication No. CMHS-SVP-0186

June 2007

iv
Contents

Executive Summary..........................................................................................................1

Section I. Defining the Public Health Context of 

Children’s Mental Health Programs..................................................................................5

Section II. Review of Effective Parenting and 

Child Resilience Programs .............................................................................................17

Section III. Understanding the Costs and Benefits of 

Prevention Programs......................................................................................................29

Section IV. Best Opportunities for Implementing 

Evidence-Based Practices To Reach Families in Need..................................................37

Section V. Recommendations for Future 

Prevention Efforts ...........................................................................................................45

Conclusion......................................................................................................................55

Acknowledgements ........................................................................................................57

References .....................................................................................................................59

v

The Senate Appropriations 

Subcommittee on Labor, 

Health and Human Services, 

and Education has charged 

the Center for Mental Health 

Services (CMHS), within the Substance 

Abuse and Mental Health Services 

Administration (SAMHSA), to review 

the effectiveness of programs that use 

a strength-based family approach to 

promoting mental wellness and preventing 

mental health problems among at-risk 

children and youth. The Committee further 

requested that CMHS identify opportunities 

and make recommendations related to 

the expanded use of such programs. 

Specifically, the Committee issued the 

following directive:

The Committee believes that 

research-based prevention 

and wellness promotion efforts 

that strengthen parenting and 

enhance child resilience in the 

face of adversity can have a 

significant impact on the mental 

health of children and youth. 

While some programs that use 

such a strengths-based approach 

exist for families already in 

contact with the juvenile justice 

system or at immediate risk for 

dissolution, evidence suggests 

that they may be particularly 

effective for families that have 

one or more risk factors but are 

not yet in crisis and may not have 

had contact with child protective 

services or other government 

agencies. The Committee 

requests CMHS to provide it 

with a report by May 1, 2006, 

that reviews the effectiveness 

of such programs and the best 

opportunities to implement them 

so they reach families in need, 

and offers recommendations

for future preventive efforts in this 

area. (Senate Report 109–103)

The purpose of this report is to respond 

to the requests made by the Committee. 

The report begins by describing the 

public health context for the promotion 

of mental health and the prevention of 

mental disorders in children.a–b It then 

describes opportunities for implementing 

evidence-based programs to reach families 

in need and summarizes the evidence 

base that shows that the programs do 

indeed strengthen the caretaking skills of 

parents and other caregivers and enhance 

child resilience.c Next, it presents current 

knowledge about the economics of these 

programs, suggests how to reach families 

with interventions, and concludes with 

a

 In this document, the term “promotion” is used in lieu of 

the phrase “promotion of mental health,” and the term “prevention” is used in lieu of the phrase “prevention of mental 

health problems or disorders.”

b

 In this report, the word “children” applies to individuals 

ages birth to age 19. The terminology for the appropriate age 

range (e.g., infants, toddlers, or adolescents) is used whenever 

the discussion relates to a specific age group. 

c

 An evidence-based program or practice is one that has been 

proven through well-designed research to demonstrate positive outcomes for participants.

Executive Summary

1
recommendations for further dissemination of 

these programs.

Half of all lifetime cases of diagnosable 

mental illnesses begin by age 14, and threefourth by age 24.1

 Focusing promotion and 

prevention efforts on children and their parents 

or other caregivers increases the likelihood 

that mental health problems in children will 

be addressed early, before they can evolve 

into full-blown mental illnesses, including 

substance abuse.d Programs aimed at older 

age groups also provide benefits, but research 

suggests that greater and more long-term 

benefits accrue when programs begin early in 

the lives of children. 

Defining the Public Health Context of 

Children’s Mental Health Programs

Promotion and prevention are key elements 

of a public health approach to mental health. 

Rather than focusing on the treatment of 

individuals who already have an illness, the 

public health approach is concerned with the 

health of an entire population. It includes 

traditional areas of medicine—diagnosis, 

treatment, and the causes of an illness—but 

it also focuses on disease surveillance, health 

promotion, disease prevention, and access to 

and evaluation of services.2 The underlying 

premise of a public health approach is that it 

is inherently better to promote health and to 

prevent illness before an illness begins. 

d This report uses the term “problems” to describe mental health 

challenges experienced by children. According to the Institute of 

Medicine, “disorder”—as defined in the American Psychiatric 

Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)—refers to “a clinically significant behavioral 

or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful 

symptom) or disability (i.e., impairment in one or more important 

areas of functioning) or with a significantly increased risk of 

suffering death, pain, disability, or an important loss of freedom 

(emphasis added) (American Psychiatric Association [2000], p. 

xxxi).” Use of the term “problem” acknowledges that not every 

child with a need for mental health care has such significant 

impairment that it qualifies as a “disorder.” 

Fundamental to the public health approach is 

the issue of risk and protection. Research and 

practice have identified risk and protective 

factors that affect the vulnerability of 

children to mental health problems. Some 

of the risk factors, such as poverty and 

community violence, cannot be eliminated 

or ameliorated by a mental health program 

alone. However, many protective factors such 

as relationship skills, conflict management, 

and positive problem-solving can be taught to 

children, family members, teachers, and other 

caregivers. 

Also fundamental to the public health 

approach is that mental health is everyone’s 

concern. Responsibility for promotion and 

prevention programs is shared across multiple 

systems, including schools, primary health 

care, mental health care, juvenile justice, child 

welfare, and substance abuse services.

Review of Effective Parenting and 

Child Resilience Programs

Family-focused, evidence-based programs 

implemented with fidelity can have a 

profound, positive effect on parenting 

behavior and the developmental trajectories 

of children whose life course is threatened 

by multiple risk factors. The knowledge base 

about programs that work is expanding and 

becoming more accessible to decision makers 

through Federal programs such as:

•	 The White House “Helping America’s 

Youth” Initiative

•	 The Prevention Research Program at 

the National Institute of Mental Health 

(NIMH) and the NIMH-sponsored doctoral 

and postdoctoral training programs in 

Prevention Research and Children’s Mental 

Health Services Research 

•	 The 10 National Academic Centers of 

Excellence on Youth Violence, sponsored 


by the Centers for Disease Control and 

Prevention

•	 The Substance Abuse and Mental Health 

Services Administration’s (SAMHSA’s) 

National Registry of Evidence-Based 

Programs and Practices. 

Understanding the Costs and Benefits 

of Prevention

Economic analyses of promotion and 

prevention programs are complex and 

costly. However, program developers 

are increasingly having the analyses 

conducted by independent organizations. 

An understanding of the costs and benefits 

of a program is extremely helpful to local 

implementers who are selecting a program for 

their community. Many programs show very 

attractive returns.3 Though small in number, 

long-term follow-up studies have shown that 

some programs continue to generate positive 

returns over a number of years as participants 

grow into healthy, well-functioning adults.

Best Opportunities for Implementing 

Evidence-Based Practices To Reach 

Parents and Other Caregivers in Need

Parents and other caregivers are a child’s 

first and foremost teachers. Promotion and 

prevention programs that address issues 

of parents and other caregivers increase 

the potential of positive outcomes. Family 

members and caregivers should be equal 

partners, along with school and community 

leaders in selecting, implementing, 

evaluating, and sustaining programs. Parents 

and other caregivers are more likely to be 

involved if services are provided in easily 

accessible settings and if they are culturally 

and linguistically appropriate.

School settings present a key opportunity 

to reach out with evidence-based programs 

to parents and other caregivers because the 

social and emotional skills taught by these 

programs usually have a positive impact on 

improving academic achievement. Primary 

health care also offers great potential to 

involve families in mental health promotion 

and prevention, and their support is extremely 

helpful when early intervention is indicated. 

Primary health care physicians currently 

identify only a small percentage of children 

with behavior and emotional problems, but 

the percentage is likely to increase if the 

physicians respond to a key conclusion of a 

recent Institute of Medicine (IOM) report. 

As stated unconditionally by the IOM, “We 

cannot improve our overall health care system 

adequately unless we pay equal attention to 

addressing the issues surrounding mental and 

substance abuse disorders.”4 

Recommendations for Future 

Prevention Efforts

Many evidence-based resilience-building 

prevention programs exist, and more are 

being developed as the need for and the value 

of these programs becomes more apparent. 

The critical next step is for more communities 

to become aware of these programs and 

to engage a broad-based coalition in 

implementing them, even while researchers 

continue to expand the knowledge base. To 

achieve this next step, government and public 

and private organizations at all levels should 

collaborate on and contribute to efforts to 

expand the development, dissemination, 

implementation, and evaluation of such 

programs and to build a workforce capable of 

working with families to ensure their greatest 

success. Broad-based recommendations 


for advancing promotion and prevention 

programs for children are to:

1.	 Communicate the good news of

prevention, including the economic and

social benefits of investing in prevention.

2. 	 Provide family members, other

caregivers, community leaders, and local

educators with the latest knowledge for

strengthening parenting and building

child resilience so informed decisions

about appropriate interventions can be

made easily.

3.	 Build on existing programs to maximize

available knowledge and resources.

4. 	 Encourage the development of the

State and local infrastructure necessary

to adopt, adapt, implement, evaluate,

improve, and sustain evidence-based

practices.

5.	 Encourage a coordinated assessment and

accountability system for promotion,

prevention, and treatment in children’s

mental health.

6.	 Examine more systematic strategies

to increase and coordinate funding for

prevention efforts across Federal and

State agencies.

7. 	 Build a workforce capable of effectively

implementing age- and culturallyappropriate evidence-based practices.

8.	 Include families in a decisionmaking role from the outset; that is,

in the planning, selection, adaptation,

implementation, evaluation, and

sustaining of programs for their children

and their communities.

Children’s mental health is the foundation 

on which they build their future lives. It is 

up to policy makers, in concert with parents 

and others who can help influence the 

outcome, to ensure that children have every 

opportunity to achieve the mental health 

status that will enable them to be successful, 

contributing members of their families, their 

communities, and their nation. 


The public health model is 

concerned with the health of 

an entire population, including 

its link to the physical, 

psychological, cultural, and 

social environments in which people live, 

work, play, and go to school. It focuses 

not only on traditional areas of medicine—

diagnosis, treatment, and etiology or cause of 

an illness—but also on disease surveillance, 

health promotion, disease prevention, 

and access to and evaluation of treatment 

services.5 The emphasis on a public health 

approach to mental health, rather than on the 

treatment of individuals with serious mental 

illnesses, has increased as more Americans 

have come to understand that mental health 

is essential to their overall health. Within 

the more inclusive public health context, all 

individuals within a community (whether 

that community is a school, a neighborhood, 

or a nation) are affected by the health of its 

individual members.

For children, mental health is not seen as 

residing solely within the child, but within 

the web of interactions among the individual 

child; the family; the school, health, and other 

child service systems; and the neighborhoods 

and communities in which the child lives.6

The public health model follows an ordered, 

continuous set of steps to promote health and 

prevent illnesses. These steps are to:



Section I. Defining the Public 

Health Context of Children’s 

Mental Health Programs
1.	 Define the problem.

2.	 Identify risk and protective factors.

3.	 Develop, implement, and test

interventions.

4.	 Ensure the widespread adoption of

evidence-based practices.

The issue of mental health problems in 

children is well acknowledged. More than 

80 million children younger than age 19 

now are growing up in the United States. 

Results from the 2005 National Survey 

on Drug Use and Health indicated that 

5.5 million youths aged 12 to 17 received 

treatment or counseling for emotional or 

behavior problems in the year prior to the 

interview.8 This is 21.8 percent of youth 

ages 12 to 17. Other estimates indicate that 

10 percent of this age group experiences a 

mental health problem serious enough to 

cause a significant level of impairment in 

functioning at home, at school, or in the 

community.9–10 If early intervention does not 

occur, childhood disorders may intensify 

and persist, often leading to a downward 

spiral of school failure, poor employment 

opportunities, and poverty in adulthood.11

The Federal Government, in partnership 

with researchers in university settings, has 

been working to identify risk and protective 

factors and to develop, test, and disseminate 

evidence-based practices. A large research 

base that traces the developmental 

pathways of children from before birth 

through adulthood has been constructed 

and continues to expand. 12–15 Many studies 

have identified factors that place children 

at risk for numerous mental and emotional 

problems later in life. Equally important, the 

research has identified protective factors in 

the child, family, community, and society at 

large that serve to reduce risk. 



Problem or Illness? 

Mental Health: A Report of the Surgeon General notes 

that mental health and mental illness are not mutually 

exclusive categories but are points on a continuum 

ranging from positive mental health through mental 

health problems to mental illnesses.7 The report 

defines these constructs as follows:

Mental health—a state of successful performance of 

mental function, resulting in productive activities, 

fulfilling relationships with other people, and the ability 

to adapt to change and cope with adversity.

Mental health problems—signs and symptoms of 

insufficient intensity or duration to meet the criteria 

for any mental disorder. Mental health problems may 

warrant active efforts in health promotion, prevention, 

and treatment. 

Mental illnesses—all diagnosable mental disorders, 

health conditions characterized by alterations in 

thinking, mood, or behavior (or some combination 

thereof) associated with distress and/or impaired 

functioning. 

Under these definitions, substance use might be 

classified as either a mental health problem or a mental 

illness, depending on its intensity, duration, and effects. 

When this document makes note of “mental health and 

behavior problems,” the phrase applies to a spectrum 

of problematic behaviors, such as defiance, impulsivity, 

truancy, and aggression. Substance use also may 

be considered a problem behavior, although not all 

“problem behavior” necessarily refers to substance use 

and abuse. Within other contexts, the term “behavioral 

health” is used as an umbrella term that encompasses 

both mental health status and substance use and 

abuse. Consequently, in these contexts, “behavioral 

health problems” refer to difficulties that an individual 

may have in either or both of these areas.
Great progress has been made in developing and testing 

interventions that build on this knowledge base and in working 

to ensure the widespread adoption of evidence-based practices. 

Of particular note are the Prevention Research Program at the 

National Institute of Mental Health (NIMH) and the NIMHsponsored doctoral and postdoctoral training programs in 

Prevention Research and Children’s Mental Health Services 

Research. The 10 National Academic Centers of Excellence 

on Youth Violence, sponsored by the Centers for Disease 

Control and Prevention, is another example of how the Federal 

Government is supporting the expansion of the evidence base 

for preventive interventions. Additionally, the Substance Abuse 

and Mental Health Services Administration’s (SAMHSA’s) 

National Registry of Evidence-Based Programs and Practices 

is identifying and disseminating evidence-based programs 

shown to be effective in the promotion of mental health and in 

the prevention and treatment of both mental and substance use 

disorders. 

Risk and Protective Factors

Successful promotion and prevention efforts hinge on the 

identification of malleable risk and protective factors. While 

a single risk factor may provide some influence, it is the 

accumulation and complex interaction of risk factors that 

increase the probability of mental illness.16 Webster-Stratton 

and Taylor describe a complex and cumulative interaction 

of numerous risk factors that come into play when children 

are toddlers and can lead to early onset of conduct problems 

(see figure 1).17 Left untreated, conduct problems often turn 

into antisocializing conditions such as substance abuse, 

delinquency, and violence.

According to Webster-Stratton and Taylor, parents and other 

caregivers often can be overwhelmed by a child’s temperament 

that is more impulsive, hyperactive, or quick to show anger. 

Their response to the child’s behavior may be an approach 

that inadvertently increases the likelihood of further conduct 

problems. Harsh and punitive discipline, for example, provides 

a negative model of behavior, fails to promote prosocial 

child behavior, and impedes the development of social and 

cognitive skills. Alternatively, “giving in” to a child reinforces 

the demanding behavior. Contextual factors, such as poverty 

and other life stressors, also can contribute to a child’s risk of 

developing conduct problems.



Health Now vs. Disease 

Later

The underlying premise of 

the public health model is the 

conviction that it is inherently 

better to promote health and to 

prevent illness before an illness 

begins. This same premise is the 

foundation of ongoing national 

public health efforts to prevent 

obesity in children rather than deal 

later with the associated and costly 

health risks of the disease. A child’s 

risk of obesity, as well as of mental 

health problems, can be diminished 

by addressing malleable risk and 

protective factors in the child’s 

environment. 
When children with risk factors enter school, 

the developmental model becomes more 

complex. Teachers, particularly those with 

ineffective classroom management skills, can 

be more critical and less supportive of children 

with challenging and evolving behavior 

problems. Limited parental involvement in 

school can compound the problem. Teachers 

who misunderstand the reasons for lack of 

parental involvement may respond critically 

to the parents and caregivers, further eroding 

the home–school bond. Over time, children 

who experience difficulty in school may find 

friends who have a similar experience and 

eventually may form deviant peer groups that 

continue to reinforce antisocial behaviors. The 

consequence of these early problems may be 

a synergistic cycle of cumulative events that 

increasingly compromise a child’s functioning 

over time. 

Webster-Stratton and Taylor maintain that 

these “cascading domains of risk factors make 

it imperative to start prevention programs 

as early as possible to ‘nip problems in the 

bud’ before they create problems that are 

more entrenched and difficult to ameliorate 

(see figure 2).” In addition, such a proactive 

approach provides an adequate foundation 

on which to build and strengthen the 

protective factors that guard against problem 

development.

However, as stated earlier, it is the 

accumulation and complex interaction of risk 

and protective factors that contribute to mental 



Child Factors

• Poor conflict management

skills

• Poor social skills

• Impulsivity, attention deficit

disorder, and difficult

temperament

•Low school readiness

Contextual/Family Factors

• Poverty

• Parent criminal activity

• Parent substance abuse

• Life stressors

• Parent mental illness

• Parent marital discord

School and Peer

Factors

• Ineffective teacher

response

• Classroom

aggression

•Poor connections

Early Onset

Conduct

Problems

Source: Webster-Stratton, C. & Taylor, T. (2001). Nipping early risk

factors in the bud: Preventing substance abuse, delinquency, and

violence in adolescence through interventions targeted at young

children. Prevention Science, 2, No. 3, 165–192. (Reproduced with the

kind permission of Springer Science and Business Media).

Parenting Factors

• Harsh and ineffective

parenting skills

• Poor monitoring

• Low cognitive stimulation

Figure 1. Risk factors related to conduct problems.


Figure 2. Synergistic cycle of cumulative events

leading to adolescent high-risk behaviors.

Deviant peer group

Early-onset

conduct problems

Adolescent substance abuse

Delinquency

Violence

Ineffective parenting

Poor monitoring

Low bonding

Poor school/teacher/

child bonding and 

academic failure

Source: Webster-Stratton, C. & Taylor, T. (2001). Nipping early risk factors in the bud: Preventing substance 

abuse, delinquency, and violence in adolescence through interventions targeted at young children. Prevention 

Science, 2, No. 3, 165–192. (Reproduced with the kind permission of Springer Science and Business Media).

health or mental illness. The prevention of 

mental health problems and behavior problems 

in young people requires, at its foundation, 

the promotion of factors required for 

positive development.18 According to Werner, 

“Protective buffers...seem to be helpful to us 

[as] members of the human race.... [They] 

appear to make a more profound impact on 

the life course of individuals who grow up 

and overcome adversity than do specific risk 

factors.”19 Protective factors as well as risk 

factors can be important targets for preventive 

intervention. Figure 3 illustrates protective 

factors that can build resilience in children and 

act as buffers against adversity.

Figures 1 through 3 link risk and protective 

factors to conduct problems, but most risk 

factors are not problem-specific and may relate 

to both emotional and behavioral outcomes. 

In addition, a single risk factor generally does 

not substantially increase the likelihood that 

a mental health or behavior problem may 

occur. Greater numbers of factors, however, 

do correlate with a higher prevalence and 

incidence of such problems. In addition, 

mental health problems, substance use, and 

various high-risk behaviors in children often 

co-occur, interact, and are related to the same 

types of risk factors. 
10

“Promotion,” “Prevention,” and “Resilience”

The public health model emphasizes the promotion of 

mental wellness as well as the prevention of mental health 

problems and disorders. Experts in New Zealand maintain that 

promotion and prevention are “inextricably linked.”20 The 

Institute of Medicine, in its landmark report entitled Reducing 

Risks for Mental Disorders, asserts that the two are distinct 

from each other and chose to focus on prevention.21

At present, no general consensus has emerged regarding the 

use of the term “prevention.” Historically, the terms primary, 

secondary, and tertiary have been used to refer, respectively, 

to prevention of the onset of a disorder, prevention of 

disability from a disorder, and prevention of relapse of 

a disorder. However, the Institute of Medicine (IOM) 

recommended restricting the use of prevention “to processes 

that occur before there is a diagnosable mental illness.” 

A major reason that the IOM defined prevention in this 

manner was that, under the old terminology, secondary and 

tertiary prevention included conditions that occur after the 

onset of a disorder. The IOM wanted to be sure that prevention 

of onset was considered to be a legitimate and highly valuable 

endeavor, worthy of investment. Because funding is limited 

and the needs of people with existing mental illnesses are 

great, very little money historically has been allocated for 

primary prevention.

The IOM went on to classify preventive interventions 

as universal, selective, and indicated. The degree of risk 

distinguishes the target population for each intervention.

•	 A universal preventive intervention is applicable or useful 

for everyone in the general population. A school-based 

social competency program such as Promoting Alternative 

Thinking Strategies (PATHS) that is offered to all students 

within a school is an example of a universal intervention. 

Because universal interventions are proactive, and 

provided independent of risk status, there is no stigma 

associated with being a participant in a program. As a 

result, individuals and communities may accept and adopt 

these programs more readily.

•	 A selective preventive intervention is targeted at 

individuals or subgroups (based on biological or social 

risk factors) whose risk of developing mental health 

problems is significantly higher than average. Examples of 

Defining the Terminology

Promotion (of mental health): 

Efforts designed to enhance an 

individual’s social competence, 

self-esteem, and sense of wellbeing.

Prevention (of mental health 

problems): Interventions that occur 

before the onset of a problem, 

as well as interventions that 

prevent relapse, disability, and the 

consequences of severe mental 

illness or substance abuse.22

Resilience: The human capacity 

to face, overcome, and even be 

transformed by adversity. 

Social and emotional learning: 

The process of acquiring the 

skills to recognize and manage 

emotions, develop caring 

and concern for others, make 

responsible decisions, establish 

positive relationships, and handle 

challenging situations effectively.23
11

selective intervention programs include 

home visitation programs for low birthweight children, preschool programs 

for all children from impoverished 

neighborhoods, and support groups for 

children who have suffered losses or other 

trauma. 

•	 An indicated preventive intervention 

is aimed at individuals who have some 

symptoms of mental health problems 

but whose symptoms are not yet severe 

or prolonged enough to meet diagnostic 

criteria. Examples of indicated preventive 

interventions for children who have early 

behavior problems are intensive parentchild programs, mentoring programs, 

and social-emotional skillbuilding for 

children. 

Some programs include interventions that 

address all three levels of prevention, and 

some implement multiple components that 

* Underlined factors apply especially to young children; italicized factors apply especially

 to adolescents.

Sources: (1) Masten, A. S. & Coatsworth, J. D. (1998). The development of competence in favorable and 

unfavorable environments: lessons from research on successful children. American Psychologist, 53, 2, 

205-220; (2) Hawkins, J. D. (2005). Promoting successful youth development. Paper presented at the White 

House Conference on Helping America’s Youth. Social Development Research Group. Washington, DC; (3) 

Mrazek, P. J. & Haggerty, R. J. (Eds.) (1994). Reducing Risks for Mental Disorders: Frontiers for Preventive 

Intervention Research. Washington, DC: National Academy Press.

Figure 3. Protective, or buffering, factors that promote resilience.*
could involve children, family members, 

and teachers as well as school, home, and 

neighborhood environments. Section II of 

this report will describe in more detail both 

single- and multiple-component preventive 

interventions.

In contrast to the IOM definition of 

“prevention” as only those actions that occur 

prior to the onset of a problem, the National 

Institute of Mental Health (NIMH) uses 

the concepts but not the terminology of the 

older classifications to construct a broader, 

more inclusive definition of prevention. The 

Institute defined prevention more broadly 

as interventions that occur not only before 

the initial onset of a disorder, “but also 

to interventions that prevent comorbidity, 

relapse, disability, and the consequences of 

severe mental illness for families.” Under 

this definition, treatment—which reduces 

the likelihood and severity of future mental 

health problems―may be classified more 

appropriately as prevention-minded treatment 

(see figure 4). For example, evidence suggests 

that treating depression in mothers increases 

the likelihood that their children will maintain 

positive mental health in later childhood.24–27 

Another important concept related to 

promotion and prevention is “resilience.” The 

term “resilience” has its origins in physics 

and architecture. To be “resilient” means that 

a building material, such as tempered steel, 

has the ability to withstand stress. This same 

term has been adapted to describe a person’s 

ability to face the challenges of life. Resilience 

often is defined as “the ability of a person to 

spring back from and successfully adapt to 

adversity.” Just like tempered steel, it means 

that an individual can withstand stress (i.e., 

adversity) and continue to function well. 

12

Source: National Institute of Mental Health (1998). Priorities for Prevention Research at NIMH: A 

Report by the National Advisory Mental Health Council Workgroup on Mental Disorders Prevention 

Research (NIH Publication No. 98-4321). Rockville, MD: Author.

Co-morbidity

Prevention Disability

Prevention

Relapse

Prevention

Maintenance

Treatment

Acute Care

Indicated

Selective

Universal

Pre-Intervention

Basic & Clinical Sciences

(Casualty, Risk Factors)

Generation III

Prevention

Generation I

Prevention

Generation II

Prevention Treatment

Figure 4. The mental health intervention spectrum.
A misleading perception regarding resilience 

is that it is a static trait of an individual. 

Instead, resilience in a person is dynamic 

and varies across time and life domains (e.g., 

relationships, academic and professional 

life, and health). Individuals do not develop 

resilience by “pulling themselves up by the 

bootstraps” when faced with life’s challenges. 

Resilient adaptation to adversity comes about 

as a result of characteristics of an individual 

interacting with resources in the environment, 

such as caring adults, good schools, safe 

neighbors, good friends, and other “protective 

factors” previously identified in figure 3. 

Evidence-based programs implemented with 

fidelity can teach many of the skills that 

correlate with resilience. These skills are 

collectively known as social-emotional skills 

and include how to recognize and manage 

emotions, develop caring and concern for 

others, make responsible decisions, establish 

positive relationships, and handle adversity 

effectively. Most developers of prevention 

programs do not describe their programs as 

“programs to foster resilience.” One who does, 

however, is Dr. Karol Kumpfer, the developer 

of the Family Strengthening Program.

28

Kumpfer clarifies the resilience and prevention 

issue as follows: 

Luckily, although not specifically designed 

to increase resilience, most prevention

programs logically or intuitively focus on 

increasing protective mechanisms. Many

of these protective mechanisms are 

synonymous with resilience mechanisms. 

Hence, increasing research findings about 

resilience-building processes should better 

inform prevention program design and 

increase program effectiveness.29

e

 Fidelity is the degree to which a program is conducted as it was 

originally designed and tested. If a community wants to adapt a 

program to its particular needs, it is essential that it work with the 

program developer to do so because adaptations often pose a threat 

to fidelity and make the program ineffective. 

The Importance of Promotion and 

Prevention to Public Health and 

Children’s Mental Health 

When measured across all age groups, mental 

illnesses are the leading causes of disability 

worldwide. Five of the top 10 diseases 

associated with significant disability and 

disease burden are mental illnesses: unipolar 

major depression, alcohol abuse, bipolar 

disorder, schizophrenia, and obsessivecompulsive disorder.30 The costs are staggering. 

Currently, the United States spends more than 

$85 billion per year for mental health and 

$18.3 billion per year for substance abuse 

treatment.31 Our Nation’s most dramatic and 

measurable consequence of undiagnosed, 

untreated, or inadequately treated mental health 

problems is suicide. Suicide claims the lives 

of approximately 30,000 American adults and 

children each year. For the year 2002, three 

individuals died as a result of suicide for 

every two individuals who died as a result of 

homicide. Suicide is the third leading cause of 

death for youth ages 15 to 24.32

The majority of lifetime mental illnesses 

begin in youth. According to the National 

Comorbidity Survey Replication, half of all 

diagnosable lifetime cases of mental illness 

begin by age 14, and three-fourths of all 

lifetime cases start by age 24.33 The survey 

further indicated that, despite the existence 

of effective treatments, there are long 

delays—sometimes decades—between the 

first onset of symptoms and when individuals 

seek and receive treatment. In addition, the 

survey results concluded that an untreated 

mental disorder can lead to more severe, more 

difficult-to-treat mental illness and to the 

development of co-occurring mental illnesses. 

The National Comorbidity Survey Replication, 

which was led by Harvard University, the 

University of Michigan, and the NIMH 

Intramural Research Program, adds to a 

13
growing body of evidence suggesting a strong 

link between mental health problems and 

other behavior problems with serious longterm consequences. A wealth of research has 

demonstrated that mental health problems 

often are precursors to delinquency, substance 

abuse, health-risking sexual behaviors, and 

school failure.34–36 Conclusions drawn from 

some of the related studies are that: 

•	 Conduct problems predict the initiation of 

alcohol use as well as greater escalations 

of alcohol use over time.37–38

•	 Children in first grade with the 

combination of hyperactivity and social 

problem-solving deficits have been found 

to have a greatly increased rate of drug and 

alcohol use when they are between 11 and 

12 years old.39

•	 Children in first grade with conduct 

problems, anxiety or depression, or 

attention deficit– hyperactivity disorder 

(ADHD) have approximately twice the risk 

of first tobacco use during fourth through 

seventh grade than do children without 

these early emotional disorders.40

•	 Social impairment in childhood is a 

critical predictor for later substance abuse 

disorders.41

•	 Children who lack prosocial behavior skills 

are likely to be rejected by their peers and 

to gravitate toward other rejected children. 

These socially isolated peer groups, 

in turn, promote substance abuse and 

involvement in antisocial activities.42 

These and other findings suggest the 

broad long-term negative consequences of 

childhood mental health problems. As a 

result, a concerted effort has been made to 

develop effective programs that can prevent 

mental problems or greatly diminish their 

impact. Research indicates that mental health 

promotion programs and prevention programs 

can contribute positively to children’s overall 

mental health and long-term well-being. 43–44 

Additionally, evaluations have demonstrated 

that evidence-based programs, when 

implemented with fidelity, are effective in 

decreasing negative consequences.45–47 

For example, in their review of evidencebased programs, Weisz and colleagues 

summarized the longer-term findings from 

several prevention programs, some of which 

are described in Section II of this report. 

Their findings suggest that the children 

who participated in prevention programs 

were continuing to demonstrate positive 

behaviors years after program participation. 

Among the reported positive outcomes were 

higher achievement and less sexual activity, 

delinquency, conduct disorder, drug use, 

and antisocial behavior than that reported in 

children who did not receive the interventions. 

In addition, other studies have identified the 

benefits to children of family skills training,48 

specifically outcomes related to reductions in 

aggression, conduct disorders, ADHD, and 

oppositional defiant disorders;49–51 as well 

as the prevention of child abuse, later drug 

abuse,52 and delinquency.53

Barriers to Implementing Prevention 

Programs

Given the evidence and availability of 

effective programs, the obvious question is 

why more prevention programs are not being 

implemented. The groundbreaking IOM 

report, entitled Neurons to Neighborhoods: 

The Science of Early Childhood Development,

provides a succinct answer. It states that

“The overarching question of whether we can 

intervene successfully in young children’s 

lives has been answered in the affirmative, and 

should be put to rest. However, interventions 

14
that work are rarely simple, inexpensive, or 

easy to implement.”54 

Numerous research papers explore the 

challenges inherent in the implementation of 

evidence-based practices. In its synthesis of the 

research, the National Implementation Research 

Network (NIRN) observes that implementation 

of an effective practice is a process, not 

an event, and takes from 2 to 4 years to 

complete. Changes in practitioner skill level, 

organizational capacity, and organizational 

culture require training, practice, and time 

to mature.55 NIRN also cites Schoenwald 

(1997), who notes that such practices will not 

be implemented on any useful scale without 

the support of political, financial, and human 

service systems across levels of government.56 

A primary challenge in implementation is the 

acquisition of initial funding. When budgets 

are limited, the costs of the practice—which 

is immediate and easily quantified—may seem 

to outweigh the benefits—which may be longterm and difficult to assign a dollar value. 

Section II. Review of Effective Parenting 

and Child Resilience Programs describes 

numerous practices shown to be effective in 

producing quantifiable and positive outcomes 

for children although these outcomes are 

not expressly stated in dollar terms. Section 

III. Understanding the Costs and Benefits 

of Prevention deals with the conceptual 

difficulties of assigning dollar values to 

outcomes. 

15
16

• The majority of lifetime mental illnesses begin in youth. Half of all diagnosable lifetime 

cases of mental illness begin by age 14, and three-fourths of all lifetime cases start by 

age 24.

• The underlying premise of a public health approach is that it is inherently better to 

promote health and to prevent illness before an illness begins. 

• For children, mental health is not seen as residing solely within the child, but within the 

web of interactions among the individual child; the family; the school, health, and other 

child service systems; and the neighborhoods and communities in which the child lives.

• While a single risk factor may provide some influence, it is the accumulation and 

complex interaction of risk factors that increase the probability of mental health 

problems. Children with greater numbers of risk factors have an increased likelihood of 

developing a mental health problem.

• Protective factors provide “buffers” that diminish the effect of risk factors and help build 

resilience in children.

• Cascading domains of risk factors make it imperative to start promotion and prevention 

programs as early as possible to “nip problems in the bud” before they create problems 

that are more entrenched and difficult to ameliorate. 

• Early intervention efforts have demonstrated effectiveness in contributing to the overall 

mental well-being of children as well as in reducing delinquency, substance abuse, 

health-risking sexual behaviors, and school failure. 

Key Points from Section I. Defining the Public Health 

Context of Children’s Mental Health Programs
Section II. 

Review of Effective Parenting 

and Child Resilience 

Programs

Overall, the conclusion to be 

drawn from the economic 

research is that prevention 

offers great potential to 

change lives and to save 

money. There is considerable evidence that 

many carefully designed interventions with 

well-defined goals, when delivered with 

fidelity, can positively affect both parenting 

behavior and the developmental trajectories 

of children whose life course is threatened 

by socioeconomic disadvantage, family 

disruption, or diagnosed disability.57

NREPP: SAMHSA’s Database of 

Evidence-Based Programs

In 1998, SAMHSA developed the National 

Registry of Effective Programs and Practices 

(NREPP) as a flexible, scientific evaluation 

system of prevention programs. In recent 

years, NREPP has been expanded so that 

it now is designed to provide the public 

with reliable information on the scientific 

basis and practicality of interventions 

that prevent and treat mental disorders, 

including substance abuse. Descriptive 

information and quantitative ratings are 

provided across several key areas for all 

interventions reviewed. This “decision 

support” tool helps States, Territories, 

community-based organizations, and other 

interested stakeholders identify interventions 

appropriate to their needs and resources. 

Current NREPP programs may be found at 

17
modelprograms.samhsa.gov. SAMHSA will be launching a 

new NREPP web site at www.nrepp.samhsa.gov by the end of 

2006.

NREPP’s criteria are reviewed annually and revised as 

necessary to reflect progress in prevention science. As of 

this writing, NREPP evaluates programs for substance abuse 

prevention and treatment, co-occurring disorders, mental 

health treatment, and promotion and prevention in mental 

health across the lifespan. Program developers may submit 

their programs for review through the web site’s “prevention 

portal.” 

Child Resilience-Building Programs

As noted in Neurons to Neighborhoods: The Science of Early 

Childhood Development, the course of development in early 

childhood can be altered by effective interventions that change 

the balance between risk and protective factors, thereby 

shifting the odds in favor of more adaptive outcomes.59 This 

finding is a scientific way of saying “an ounce of prevention 

is worth a pound of cure.” The following promotion and 

prevention programs are drawn from the NREPP database 

(modelprograms.samhsa.gov). The programs are listed by 

age range and according to their categorization as universal, 

selective, or indicated. Each program has demonstrated 

effectiveness in addressing the risk and protective factors 

described in Section I. 

18

A Framework for 

Effective Programs 

Weissberg58 and others 

have identified the following 

characteristics as essential to 

delivering coordinated prevention 

programming that works. The 

characteristics are that a program: 

1. Uses a research-based risk 

and protective factor framework 

that involves families, peers, 

schools, and communities 

as partners to target multiple 

outcomes.

2. Is long-term, age specific, and 

culturally appropriate.

3. Fosters development of 

individuals who are healthy and 

fully engaged through teaching 

them to apply social-emotional 

skills and ethical values in daily 

life.

4. Aims to establish policies, 

institutional practices, and 

environmental supports that 

nurture optimal development.

5. Selects, trains, and supports 

interpersonally skilled staff 

to implement programming 

effectively.

6. Incorporates and adapts 

evidence-based programming 

to meet local community needs 

through strategic planning, 

ongoing evaluation, and 

continuous improvement.
19

 Programs for Infants and Young Children

High/Scope Perry Preschool Program

High/Scope Perry Preschool Program (High/Scope) (Universal) works closely with parents 

and other caregivers and uses an active learning approach to educating children, imparting 

skills that will support their development through school and into young adulthood. Based on 

more than 40 years of scientific research, it provides teachers and caregivers with a blueprint 

for daily routines, classroom and playground organization, and teacher-child interaction, 

all designed to create a warm, supportive learning environment. In addition, this learning 

environment encourages independent thinking, initiative, and creativity. A key component of 

the program is home visits by the child’s teacher. Educators and caregivers meet formally and 

informally to exchange information about how to promote and extend children’s learning and 

development at home. Program goals are for young children to:

• Learn through active involvement with people, materials, events, and ideas. 

• Become independent, responsible, and confident, ready for school and ready for life. 

• Learn to plan and execute activities, then talk with other children and teachers about what 

they have done and what they have learned (Plan-Do-Review).

• Gain knowledge and skills in important content areas, including language and literacy, 

initiative and social relationships, creative representation, movement, music, mathematics, 

and logical thinking. 

Positive outcomes: When compared to a control group, the participant group at age 27 had:

•	 63 percent fewer habitual criminals (five or more lifetime arrests)

•	 26 percent fewer adult welfare or other social service recipients

•	 68 percent fewer arrests for drug dealing

•	 Nearly twice the rate of home ownership

•	 Nearly three times as many earning $2,000 or more per month (1992 dollars). 
The Incredible Years

The Incredible Years (Universal, selective, indicated) features three comprehensive, multifaceted, and developmentally based curricula for parents and caregivers, teachers, and 

children. The program is designed to promote emotional and social competence and to 

prevent, reduce, and treat emotional and behavior problems in young children (2 to 8 years 

old). Young children with high rates of aggressive behavior problems have been shown to 

be at great risk for developing substance use problems, becoming involved with deviant peer 

groups, dropping out of school, and engaging in delinquency and violence. Ultimately, the aim 

of the teacher-, parent-, and child-training programs is to prevent and reduce the occurrence 

of aggressive and oppositional behavior in children, thus reducing their chance of developing 

later delinquent behaviors.

Positive outcomes: According to standardized reports by teachers, parents, and caregivers: 

•	 At least 66 percent of children previously diagnosed with oppositional defiant disorder/

conduct disorder whose parents and caregivers received the parenting program were in the 

normal range at both the 1-year and 3-year follow-up assessments. 

•	 When children who participated in the program were compared with children who did not 

participate, participants had greater problem-solving skills, greater use of prosocial conflict 

management strategies with peers, increased appropriate play skills, and reduced conduct 

problems at home and at school.

20
21

Nurse–Family Partnership (NFP)

Nurse–Family Partnership (NFP) (Selective) provides first-time, low-income mothers of 

any age with home visitation services from public health nurses. NFP nurses begin making 

home visits while the mother is still pregnant (before the 28th week, and ideally between 

the 12th and 20th week) and continue through the first 2 years of the child’s life. The nurses 

work intensively with these mothers to improve maternal, prenatal, and early childhood 

health and well-being, with the expectation that this intervention will help achieve longterm improvements in the lives of at-risk families. Starting with expectant mothers, the 

program addresses substance abuse and other behaviors that contribute to family poverty, 

subsequent pregnancies, poor maternal and infant outcomes, suboptimal childcare, and a lack 

of opportunities for the children. The intervention process is effective because it focuses on 

developing therapeutic relationships with the family and is designed to improve five broad 

domains of family functioning:

•	 Health (physical and mental) 

•	 Home and neighborhood environment 

•	 Family and friend support 

•	 Parental roles 

•	 Major life events (e.g., pregnancy planning, education, employment). 

Positive outcomes: A 15-year follow-up study with the first cohort of program participants 

found that, when compared to a control group, the intervention group showed a:

•	 79 percent reduction in child abuse and neglect

•	 44 percent reduction in maternal behavior problems due to substance abuse

•	 69 percent reduction in maternal arrest rates 

•	 54 percent fewer arrests and 69 percent fewer convictions among the 15-year-old 

adolescents

•	 58 percent fewer sexual partners among the 15-year-old adolescents

•	 28 percent reduction in cigarette smoking by the 15-year-old adolescents.
22

 Programs for Children and Early Adolescents

Promoting Alternative Thinking Strategies (PATHS)

Promoting Alternative Thinking Strategies (PATHS) (Universal, selective) is a 

comprehensive program for promoting emotional and social competencies and reducing 

aggression and acting-out behavior in children ages 5 to 12, while simultaneously enhancing 

the educational process in the classroom. This innovative curriculum for kindergarten through 

sixth grade is used by educators and counselors as a multiyear prevention model. The PATHS 

curriculum provides teachers with systematic and developmentally based lessons, materials, 

and instructions for teaching their students emotional literacy, self control, social competence, 

positive peer relations, and interpersonal problem-solving skills. 

Positive outcomes: In various studies that used a control group, PATHS has shown a:

•	 32 percent reduction in teachers’ reports of students exhibiting aggressive behavior

•	 36 percent increase in teachers’ reports of students exhibiting self-control

•	 20 percent increase in students’ scores on cognitive skills tests.
23

Olweus Bullying Prevention

Olweus Bullying Prevention (Universal) is a multilevel, multicomponent school-based 

program designed to prevent or reduce bullying in elementary, middle, and junior high 

schools (students ages 6 to 15 years). The program attempts to restructure the existing school 

environment to reduce opportunities and rewards for bullying. School staff members primarily 

are responsible for introducing and implementing the program. Their efforts are directed 

toward improving peer relations and making the school a safe and positive place for students 

to learn and develop. Intervention against bullying is particularly important to reduce the 

suffering of the victims. However, it also is highly desirable to counteract these tendencies for 

the sake of the aggressive students because bullies are much more likely than other students to 

expand their antisocial behaviors. Reducing aggressive, antisocial behavior also may reduce 

substance use and abuse.

Positive outcomes: Program outcomes indicate that, compared to a control group, participants 

showed a:

•	 30 to 70 percent reduction in student reports of being bullied and bullying others

•	 Significant reductions in student reports of general antisocial behavior (e.g., vandalism, 

fighting, and truancy)

•	 Significant improvements in classroom order and discipline

•	 More positive attitudes toward schoolwork and school.

Family Effectiveness Training (FET)

Family Effectiveness Training (FET) (Indicated) is a family-based program developed 

for and targeted to Hispanics and designed to reduce risk factors and increasing protective 

factors related to adolescent substance use and related disruptive behaviors. FET, applied 

in the pre-adolescent years (ages 6 to 12), targets three family factors that place children at 

risk as they make the transition to adolescence: 1) problems in family functioning, 2) parent–

child conflicts, and 3) cultural conflicts between children and parents and other caregivers. 

Interventions employed by FET cover normal family changes during the children’s transition 

to adolescence and teach conflict resolution skills, alternatives to substance use, parent and 

family supervision of children and their peer relationships, and family communication and 

parenting skills. 

Positive outcomes: Program evaluations showed that, when compared to a control group, 

participants in the intervention group showed a:

•	 35 percent reduction in children’s conduct problems

•	 66 percent reduction in children’s associations with antisocial peers

•	 34 percent reduction irresponsible behaviors

•	 75 percent improvement in family functioning.
24

Families and Schools Together (FAST) 

Families and Schools Together (FAST) (Universal, selective, and indicated) is a multifamily 

group intervention designed to build protective factors and reduce the risk factors associated 

with substance abuse and related problem behaviors for 4- to 12-year-old children and their 

parents and caregivers. FAST systematically applies research on family stress theory, family 

systems theory, social ecological theory, and community development strategies to achieve its 

four goals:

•	 Enhanced family functioning 

•	 Prevention of school failure by the targeted child 

•	 Prevention of substance abuse by the child and other family members 

•	 Reduced stress from daily life situations for parents and caregivers and children. 

Positive outcomes: Compared to a control group, children who participated in this program 

had statistically significant reductions in aggression and anxiety and increases in academic 

competence and social skills. Specifically, results indicate a:

•	 20 percent teacher-reported improvement in school-related behavior (e.g., bullying, hitting, 

stealing, and lying)

•	 25 percent parent-reported improvement in at home related behavior (e.g., misconduct, 

anxiety, and attention span problems)

•	 15 percent teacher-reported reduction in anxiety/withdrawal

•	 15 percent teacher-reported reduction in attention span problems.

Second Step

Second Step (Universal) is a classroom-based social skills program for preschool through 

junior high students (ages 4 to 14). It is designed to reduce impulsive, high-risk, and 

aggressive behaviors, and to increase children’s social-emotional competence and other 

protective factors. Group discussion, modeling, coaching, and practice are used to increase 

students’ social competence, risk assessment, decision-making ability, self-regulation, and 

positive goal setting. The program’s lesson content varies by grade level and is organized 

into skill-building units covering empathy, impulse control, problem solving, and anger 

management. 

Positive outcomes: Controlled studies have shown the following:

•	 20 percent reduction in physical aggression during lunch and recess (compared to a 41 

percent increase among control group students) 

•	 36 percent reduction in aggressive behavior during conflict/arousing situations

•	 41 percent reduction in the need for adult interventions during conflicts 

•	 37 percent greater likelihood that participants will choose positive social goals.
25

 Programs for Adolescents

The Strengthening Families Program

for Parents and Caregivers and Youth

 The Strengthening Families Program for Parents and Caregivers and Youth

(Universal, selective) is a video-based intervention designed to reduce adolescent substance 

abuse and other problematic behaviors in 10- to 14-year-old youth. The program is delivered 

within parent, youth, and family sessions using narrated videos that portray typical youth 

and parent situations. Sessions are highly interactive and include role-playing, discussions, 

learning games, and family projects designed to:

•	 Improve parenting skills 

•	 Build life skills in youth 

•	 Strengthen family bonds. 

Positive outcomes: In a controlled test, the benefits of the program were shown to be a:

•	 30 to 60 percent reduction in substance abuse (depending on the drug) by youth

•	 32 to 77 percent reduction in conduct problems by youth (depending on the behavior) at a 

4-year follow-up point

•	 Increased resistance to peer pressure by youth

•	 Delayed onset of problematic behaviors by youth

•	 Increased ability by parents and caregivers to set appropriate limits and show affection to 

and support for their children. 
26

Brief Strategic Family Therapy

Brief Strategic Family Therapy (Indicated) is a problem-focused and practical approach 

to eliminating substance use risk factors by reducing problem behaviors in children and 

adolescents, ages 6 to 17 years, and by strengthening their families. The program fosters 

parental leadership, appropriate parental involvement, mutual support among parenting 

figures, family communication, problem solving, clear rules and consequences, nurturing, 

and shared responsibility for family problems. In addition, the program provides specialized 

outreach strategies to bring families into therapy. Focused interventions target: 

•	 Conduct problems 

•	 Associations with antisocial peers 

•	 Early substance use 

•	 Problematic family relations. 

Positive outcomes: Randomized tests that focused on changes over time between intervention 

groups and control groups measured a:

•	 42 percent reduction in conduct problems in the intervention group

•	 75 percent reduction in marijuana use in the intervention group

•	 55 percent reduction in associations with antisocial peers in the intervention group. 

Parenting Wisely

Parenting Wisely (Selective, indicated) is a self-administered, computer-based program 

that teaches parents and caregivers and their 9- to 18-year-old children important skills for 

combating risk factors for substance use and abuse. The Parenting Wisely program uses 

a risk-focused approach to reduce family conflict and child behavior problems, including 

stealing, vandalism, defiance of authority, bullying, and poor hygiene. The highly interactive 

and nonjudgmental format accelerates learning. Parents and caregivers can use new skills 

immediately. (Semi-illiterate parents and caregivers can access the program through a feature 

that enables the computer to read text portions aloud. Program materials also are available in 

Spanish.) The goals of the Parenting Wisely program are to:

•	 Reduce children’s aggressive and disruptive behaviors 

• Improve parenting skills 

• Enhance family communication 

• Develop mutual support 

• Increase parental supervision and appropriate discipline of their children.

Positive outcomes: Studies that randomized parents to intervention and control groups indicate 

positive outcomes for parents in the intervention group:

•	 38 percent increase in participation in parent education classes

• 30 percent reduction in maternal depression

• 25 percent improvement in general family functioning

• 35 to 58 percent reduction in child problem behaviors. 
27

Reconnecting Youth

Reconnecting Youth (Selective) is a school-based prevention program for youth in 9th 

through 12th grade (ages 14 to 18) who are at risk for school dropout. These youth also 

may exhibit multiple behavior problems, such as substance use, aggression, depression, or 

suicide risk behaviors. Reconnecting Youth uses a partnership model involving peers, school 

personnel, and parents and caregivers to deliver interventions that address the three central 

program goals:

•	 Decreased drug involvement 

•	 Increased school performance 

•	 Decreased emotional distress.

Positive outcomes: When compared to students in a control group, participants in 

Reconnecting Youth showed a: 

•	 48 percent decrease in anger and aggression problems

•	 32 percent decline in perceived stress

•	 23 percent increase in self-efficacy

•	 54 percent decrease in hard drug use

•	 33 percent of students reported an end to alcohol use. 

The programs described in this report are a sample of the many model and effective 

programs listed in NREPP. Many of these programs report results in terms of reductions 

in risk factors or increases in protective factors related to depression, anxiety disorders, 

conduct disorders, and substance use and abuse as well as in terms of strengthened parenting 

and enhanced child resilience. As noted earlier, children at risk of mental health problems 

also are at risk of substance use problems due to the commonality of risk and protective 

factors. This relationship suggests the existence of a “window of opportunity” in which it 

may be possible to prevent the development of co-occurring mental health problems and 

substance use disorders in youth by intervening early.60 For children and adolescents at risk, 

comprehensive programs that are family-focused, culturally appropriate, and available on a 

long-term basis are proving effective.
28

• The course of development in early childhood can be altered by effective interventions 

that change the balance between risk and protective factors, thereby shifting the odds in 

favor of more adaptive outcomes.

• There is considerable evidence that carefully designed interventions with welldefined goals, implemented with fidelity, can affect both parenting behavior and the 

developmental trajectories of children whose life course is threatened by socioeconomic 

disadvantage, family disruption, or diagnosed disability. 

• Promotion and prevention programs that target multiple domains, such as the child, the 

family, and the school can produce positive and accumulating outcomes in each domain.

• Rigorous research evaluations document substantial positive outcomes in terms of 

reduced risk factors for mental health problems (e.g., poor social skills) and in terms of 

enhanced protective factors (e.g., stronger problem-solving skills for the child and more 

effective parenting by a parent or caregiver).

• This relationship between mental health problems and substance abuse disorders in 

youth suggests the existence of a “window of opportunity” in which it may be possible 

to prevent the development of co-occurring problems through comprehensive earlyintervention programs that are family-focused, culturally appropriate, and available on a 

long-term basis.

Key Points from Section II. Review of Effective 

Parenting and Child Resilience Programs 
Section III. Understanding 

the Costs and Benefits of 

Prevention Programs

P

revention programs must make 

economic sense as well as 

demonstrate effectiveness in 

achieving desired outcomes. If 

effective programs cost more 

money than they ultimately save, the necessary 

motivation and funding for their widespread 

implementation is highly unlikely. Costbenefit analyses have provided strong evidence 

indicating that many programs are costeffective as well as successful at preventing 

undesirable outcomes. These analyses also 

have identified some of the programs that do 

not work and are not cost-effective. 

Cost-benefit analysis evaluations focus on 

multiple outcomes, expressed specifically in 

dollar terms. They also collect data at time 

points well beyond the receipt of services. 

Consequently, these evaluations are wellsuited for preventive interventions, which 

often generate costs in the present and accrue 

benefits in the future. To offer a complete 

picture, the entire stream of benefits and costsavings should be considered, whether these 

accrue to the child, the family, the government, 

or society, and whether they are recouped 

immediately or when the child matures. For 

example, the child may grow into an adult who 

participates more in civic and social activities 

(e.g., voting or volunteering), which contribute 

to the quality of life in the community and its 

well-being. The government will experience 

multiple longer term benefits, such as higher 

29
30

income tax revenues generated by higher 

employment rates. Governments also will 

recognize cost-savings from lower welfare and 

public assistance payments and from reduced 

expenditures for law enforcement and the 

justice system.

Cost-benefit analysis is a sophisticated form 

of evaluation. The primary aim is to provide 

information of use to policymakers. The 

information might be used to assess and refine 

current policy or to develop new policies. 

However, empirical cost-benefit analyses in 

the area of prevention are few in number—in 

some cases, due to the absence of information 

needed for the analysis and, in other cases, 

because the expense of conducting an analysis 

that includes the quantification of a wide range 

of costs and benefits is prohibitive.

The metric of the cost-benefit analysis is 

dollars, and quantifying the benefits of 

interventions with children in financial terms 

is difficult as their financial contribution 

to society is many years away. In addition, 

a financial accounting of “benefit” is not 

the goal of many programs targeting less 

tangible outcomes such as better self-esteem 

or more effective parenting. In spite of 

these difficulties, it is important to examine 

the information that a cost-benefit analysis 

provides. Prevention advocates often are asked 

to make their case with hard financial data. 

Accountability demands proof that prevention 

is not only the right thing to do, but that it also 

is a financially prudent thing to do. 

A number of economic evaluations of 

prevention and early intervention programs 

have been published in recent years.61–67 This 

section highlights some of these evaluations. 

It is important to recognize, however, 

that economic evaluations are not part of 

every intervention study.68 Thus, there are 

interventions that have been shown to be 

effective at reducing mental health problems 

but lack a quantified economic value. In 

addition, many of the systematic methods 

that have been developed for measuring the 

economic costs of social interventions were 

originally designed for evaluating substance 

abuse interventions.69–70 These methods, 

however, have been applied successfully to 

mental health programs.71–72 

Calculating the Benefits of Programs

Benefits from interventions commonly are 

measured in terms of reductions in cost 

associated with a health problem. Benefits 

from prevention programs often include 

decreases in the use of government, familial, 

or societal resources, which can be assigned 

dollar values. In terms of school performance, 

benefits from prevention programs may 

include reduction in school absence73 or a 

reduced need for special education services. 

In terms of juvenile delinquency, benefits 

may include reduced costs of incarceration 

and victim burden.74–78 Within the foster care 

system, benefits may include reductions in 

expenditures on out-of-home placements and 

residential treatment. 

The prevention of even a small percentage of 

mental and behavior problems will result in 

substantial cost savings and improved quality 

of life for children, families, and communities. 

Conversely, failure to increase needed access 

to proven programs will continue to exact 

a heavy personal toll and a heavy financial 

burden on workplaces; the educational, 

welfare, and justice systems; and in State and 

national economies. 

Another example of the cumulative and 

far-reaching consequences of unaddressed 
mental health problems is that 50 percent 

of adolescents with serious emotional 

disturbances drop out of high school.79

Additionally, individuals who first exhibit 

symptoms of mental health disorders in 

childhood tend to consume a disproportionate 

amount of health care services as adults.80

Benefits can be measured in positive, 

strength-based “quality of life” terms as well 

as in reductions of negative consequences 

and their costs. Many economic analyses 

use an economic “human capital” model to 

estimate the benefits of positive aspects such 

as lifetime earnings and civic participation. 

The benefits of a program, however, often 

are more difficult to determine than the costs, 

especially when they include measures of 

improved quality of life. The process also 

is made more complex because individuals 

outside of the intervention’s target group may 

experience indirect benefits, such as when a 

mental health program reduces the incidence 

of drinking and driving, and then auto 

insurance consumers as a group benefit from 

lowered premiums. Other societal benefits 

from preventive intervention programs 

may include increased tax revenue if more 

individuals are employed. 

The timeframe in which benefits are 

calculated is of special consideration when 

assigning monetary value to the benefits 

from a preventive intervention. Interventions 

such as early childhood education programs 

may continue to produce benefits throughout 

a program participant’s lifetime. Longterm net benefits may be positive, but can 

take years to accrue. Indeed, some early 

intervention programs may show immediate 

positive behavior changes but not be deemed 

beneficial in an economic framework until the 

individuals reach adulthood. 

These challenges related to benefit measures 

have the effect of potentially underestimating 

the benefits of prevention programs relative 

to the costs. As a result, most cost-benefit 

studies are viewed as conservative in nature; 

that is, it is unlikely that a cost-benefit 

analysis will overestimate the benefits of an 

intervention relative to the costs.81 In spite of 

these challenges, numerous studies document 

the positive economic value of prevention 

programs. 

Specific Cost-Benefit Analyses

A recent report from the Washington 

State Institute for Public Policy reviewed 

economic benefits of a number of researchbased preventive interventions for children 

and adolescents.82 The report focused on 

interventions designed to lower child abuse 

and neglect, reduce domestic violence, 

improve educational outcomes, reduce crime, 

lower substance abuse, decrease adolescent 

pregnancy, or reduce adolescent suicide 

attempts. Table 1 on page 38 presents a 

sample of the programs reviewed by the 

institute. 

As Table 1 illustrates, universal, selective, 

and indicated preventive interventions 

provide very attractive returns on initial 

investments. For each of the interventions, the 

table provides total benefits and total costs, 

as well as the net benefit (benefits minus 

costs) for each child who participated in the 

prevention program. The last column is the 

most significant, indicating the net economic 

advantage per child. Universal interventions 

(those that target all children) appear to 

generate lower benefits when compared to the 

selective and indicated interventions. These 

programs, however, are cost effective because 

the programs are relatively inexpensive to 

implement and they produce benefits for 

larger numbers of program participants. 

31
32

Source: Adapted from: Aos, S., Lieg, R., Mayfield, J., Miller, M., and Pennucci, A. (2004). Benefits and Costs 

of Prevention and Early Intervention Programs for Youth. Olympia: Washington State Institute for Public 

Policy.

Dollars (2003)

Program Type of Prevention Type of 

Prevention

Benefits Costs Benefits 

Minus 

Costs

Good Behavior 

Game

Elementary school 

students

Universal $204 $8 $196

Child Development 

Project

Elementary school 

students

Universal $448 $10 $432

Life Skills Training Elementary and 

middle school 

students

Universal $746 $29 $717

Seattle Social 

Development 

Project

Elementary school 

students, parents, 

and teachers

Universal $14,426 $4,590 $9,836

Strengthening 

Families

Parents and youth

(ages 10–14)

Universal

Selective

$6,656 $851 $8,805

Nurse-Family 

Partnership

Low-income pregnant 

women

Selective

Indicated

$26,298 $9,118 $17,180

Multisystemic 

Therapy

Youth (ages 11–17) Indicated $14,996 $5,681 $9,315

Table 1.

Summary of Estimated Benefits and Costs Per Youth

for a Sample of Prevention Interventions
33

True Measures of Promotion and Prevention Programs 

For those who work directly with children at risk of mental health problems, the real-life benefits 

of promotion and prevention programs are obvious, and particularly for children whose home and 

community environments are undermining their belief in themselves and their ability to succeed. 

According to Anita Hicks, the Incredible Years program supervisor for the Osborn School District 

in Phoenix, AZ, “Most of our kids are coming to us without ever having had any kind of schooling. 

They don’t know how to behave in a structured environment.” In addition, many of these same 

children have experienced significant loss or trauma, such as the incarceration of a parent. They 

have an even more difficult time succeeding in school. The following paragraph describes the 

mental health growth achieved by a young girl who participated in the Incredible Years program in 

her elementary school.

“Mandy” is a little girl whose early childhood experiences include extreme poverty, abuse, sexually 

assaulted siblings, incarceration of her father, and frequent moves. As a kindergartner, she started 

the school year with the verbal ability of a 2-year-old. The Incredible Years program gave her a 

new vocabulary, and she began to use it. Mandy now is able to give voice to her own feelings and 

to help others to express theirs. In the classroom and on the playground, she helps students and 

teachers alike to identify how they might be feeling and encourages them to behave appropriately. 

Overall, the program has helped her improve her social skills and her classroom behavior and 

increased her participation in learning activities. These are the kinds of social, emotional, and 

educational behaviors that will help Mandy achieve her full potential as a mentally healthy and 

contributing member of her community. 

33
Longer timeframes for calculating accrued 

benefits tend to improve cost-benefit ratios.83 

Effective early childhood education programs 

for at-risk children become increasingly 

cost-effective over time, partly because the 

monetary benefits increase dramatically as the 

participants enter their earning years.84–86 One 

example is the High/Scope Perry Preschool 

program, designed to improve the cognitive 

and social development of low-income, 3-

year-olds with developmental delays. The 

program included daily attendance at an 

enriched preschool program and weekly home 

visits by the preschool teachers for 2 years. 

The program was effective in increasing 

the educational attainment of the children 

and decreasing teen pregnancies. Followup evaluations with the participants at age 

40 also demonstrated program effectiveness 

in increasing their employment and earned 

incomes and decreasing criminal activities 

and their use of public assistance as adults. 

Based on these benefits, there was a calculated 

benefit of $258,888 per child by the time the 

children were 40 years old.87

These findings for the High/Scope Perry 

Preschool program emphasize the importance 

of evaluating a wide range of outcomes for 

a number of years following the completion 

of an intervention. They also point out the 

benefits across systems of government. Of 

the $258,888 total benefits, $63,267 per child 

were realized primarily in terms of higher 

earnings as adults. The majority of benefits 

were crime-related, and constituted savings 

to taxpayers, potential crime victims, and the 

criminal justice system. 

From another study in Michigan, a Statelevel analysis of the costs associated with 

child maltreatment and its consequences were 

compared to the costs of providing child 

maltreatment prevention services to all firsttime parents.88 According to this study, the 

cost of child abuse in Michigan was estimated 

at $823 million annually. These costs included 

those associated with low birth-weight 

babies, infant mortality, special education, 

protective services, foster care, juvenile and 

adult criminality, and psychological services. 

The costs of prevention programming were 

estimated to be $43 million annually. In dollar 

terms, Michigan gained $19 in benefits for 

every $1 invested in prevention. 

Finding financial support to implement 

prevention interventions is not always 

easy. In general, it may prove easier to find 

support for indicated programs that target 

children who are obviously in need and which 

produce an immediate benefit, such as the 

reduction of juvenile crime in response to a 

program for juvenile offenders. In contrast, 

it may be more difficult to obtain funding for 

universal and selective programs that have 

benefits that are less visible immediately, 

such as increased high school graduation 

rates resulting from an early childhood 

education program.89 Economic evaluation 

studies provide justification for investments 

in programs with long-term outcomes. 

Because few scientifically rigorous economic 

evaluations exist, and because recent advances 

have occurred in evaluation methodology, 

government, and public policy reports have 

pointed out the need to continue to use the 

highest standards of science to evaluate the 

economics of prevention programs.90–91

34
35

• The costs of conducting preventive interventions must be considered within the context 

of the costs of not conducting programs. Prevention of even a small percentage of 

mental and substance abuse problems will result in substantial cost savings and 

improved quality of life for children, families, and communities. 

• The benefits of preventive interventions should be measured both in terms of economic 

costs (e.g., reduction in crime-related costs) and in positive, quality-of-life terms (e.g., 

greater employability or earnings) that can take into account the long-term contributions 

a child can make to the community as a fully productive adult.

• Current data suggests that preventive interventions provide both short-term and longerterm economic benefits and are highly beneficial. Some interventions that occur early in 

life may continue to produce benefits throughout a program participant’s lifetime. 

• As evidenced by the High/Scope Perry Preschool program, quality preschool programs 

for young children living in poverty contribute to their intellectual, academic, and social 

development in childhood and to their economic performance and reduced commission 

of crime in adulthood.

• As experienced by Michigan, the benefits that accrued from a prevention program aimed 

at strengthening and improving the quality of care for young children far outweigh its 

initial cost. 

Key Points from Section III. Understanding the Costs 

and Benefits of Prevention Programs
36
Section IV. Best 

Opportunities for 

Implementing 

Evidence-Based Practices 

To Reach Families in Need

37

I

nvolving families who experience 

multiple risk factors in evidencebased programs often is difficult.92

This difficulty does not stem from 

lack of parental concern, but more 

often is a consequence of their being 

involved only minimally in decisions made 

about services and program planning in 

general. Environmental circumstances that 

make interventions less accessible also 

may contribute to less family involvement. 

Consequently, efforts to reach families in 

need must recognize their role as informed 

decision makers, offer services in accessible 

settings, and consider culture and other 

family-based strengths in designing and 

providing services. 

Recognizing Family Members and 

Other Caregivers as Decision Makers

Responsibility for children’s mental health 

care is shared across multiple systems, 

including schools, primary health care, 

juvenile justice, child welfare, and substance 

abuse prevention and treatment providers. 

The first system, however, is the family.93

Successfully involving parents and other 

caregivers in evidence-based practices 

requires the existence of decision making 

mechanisms and processes that include 

them as equal, informed, and empowered 

participants. Such mechanisms need to be 

accessible to family member participation 

in terms of location, time, and language, 

and they need to include norms that convey 
parity in decision making and respect for 

the knowledge and experience that family 

members contribute to the decision-making 

process. Parents and other caregivers should 

be full participants in decision making at 

the service delivery level with respect to 

their own child. In addition, they should 

have meaningful involvement at the system 

level in developing policies and helping to 

plan, implement, and evaluate programs 

and services affecting other children in the 

community. 

Families and other caregivers are the most 

direct source of information about needed or 

desired services. For example, parents who 

are young, inexperienced, or struggling with 

emotional or financial stress might welcome 

information about child development and 

training in parenting practices. Research has 

substantiated the prevalence of depression, 

domestic violence, and substance abuse among 

women who have low incomes.

94 Families 

who might be experiencing a combination of 

risk factors in addition to financial hardship 

can provide detailed insight into the kinds 

of supports and services that might help to 

stabilize the adults and the home environment 

for the children.

In the arena of public mental health treatment 

services, family participation is a wellestablished concept. Family and professional 

partnerships have become rooted firmly in the 

overarching principle of family involvement. 

Family- and consumer-driven care, as well 

as the involvement of family members and 

other caregivers in planning, evaluating, 

and implementing evidence-based practices, 

have gained momentum and support in the 

public mental health community.95–96 For 

example, family leaders can provide insight 

into local settings, such as in a local church 

or elementary school, that may be receptive 

to having a positive parenting program taught 

there. These same settings also hold great 

potential for increasing the awareness of the 

effectiveness of available preventive practices 

in the community at large. 

Providing Services in Settings Easily 

Accessible by Parents and Other 

Caregivers

Involving families and other caregivers in 

evidence-based practices is strengthened 

through methods of service delivery that are 

easily accessible by them. Home visitations 

by trained health care professionals offer 

one option for making an evidence-based 

practice easily accessible to families. The 

Nurse–Family Partnership (described in 

Section II of this report) is a well-studied and 

cost-effective home visitation program that is 

being disseminated currently in a number of 

States. An overarching factor that accounts 

for its success is the ability of the nurse 

home visitors to “...develop an empathic and 

trusting relationship with the mother and other 

family members....”97 Young mothers report 

that they felt comfortable having the nurse 

visit them instead of being asked to go to a 

clinic or office. The intervention begins in 

pregnancy, lasts through the first 2 years of 

the children’s lives, and illustrates the need for 

longer-term interventions for families that are 

hard to reach.

Another home visitation model was used by 

several grantees in SAMHSA’s Prevention 

and Early Intervention Program to involve 

parents whose children were having difficulty 

in kindergarten and first and second grades. A 

family mentor or coach was hired to work with 

parents who had little or no relationship with 

the school. Repeated home visits to reluctant 

parents helped to involve them in discussing 

a child’s emotional or behavior problem, and 

38
it provided an opening for the coach/mentor 

to implement an evidence-based positive 

parenting practice (i.e., the Incredible Years). 

Through a trusting relationship with home 

visitors, families with multiple mental health 

and social problems have an opportunity 

to explore and become motivated to accept 

referrals for community mental health, 

substance abuse, and social services and to 

participate in an evidence-based positive 

parenting intervention.

Primary care settings offer another 

opportunity to reach families in need. Primary 

care is a natural point of contact for families 

and a place where a child’s mental health 

problem, as well as risk factors related to 

the onset of mental health problems, could 

be addressed openly as part of an overall 

discussion of health. Of all the children they 

see, primary care physicians identify about 

19 percent with behavior and emotional 

problems.98

Primary health care professionals can be a 

crucial link between children at risk of mental 

health problems and needed interventions. 

Kahn and colleagues surveyed more than 550 

mothers who used a primary care provider.

Eighty-five percent of the women indicated 

that they would be receptive to being 

asked questions about specific risk factors, 

including unintended pregnancy; emotional, 

verbal, and physical abuse; and self-assessed 

health concerns. Ninety percent of the women 

said they would welcome an offer of help 

with making referral appointments for these 

issues.99

The Georgetown University National 

Technical Assistance Center for Children’s 

Mental Health recently published a 

monograph on the interface between primary 

health care and mental health and substance 

abuse services. Entitled The Best Beginning: 

Partnerships Between Primary Health Care 

and Mental Health and Substance Abuse 

Services for Young Children and Their 

Families, the monograph reviews a variety 

of innovative strategies used to connect 

families in a primary care practice to local 

mental health and substance abuse treatment 

professionals.100 Even though the report 

focuses on families with infants and toddlers, 

lessons learned from the strategies reviewed 

can be applied to primary care and pediatric 

practices that work with older children 

and their families. Some of the strategies 

suggested by this report include:

•	 Implementing a medical home model. A 

medical home is not a building, house, 

or hospital but rather an approach to 

providing comprehensive primary care. 

A medical home is defined as primary 

care that is accessible, continuous, 

comprehensive, family-centered, 

coordinated, compassionate, and 

culturally effective. A medical home 

addresses how a primary health care 

professional works in partnership with the 

family to ensure that all of the medical 

and nonmedical needs of the patient are 

met. Through this partnership, the primary 

health care professional can help the 

family access and coordinate specialty 

care, educational services, in- and outof-home care, family support, and other 

public and private community services 

that are important to the overall health of 

the patient and family. 

A medical home is especially valuable for 

children with special needs. Some actions 

consistent with a medical home model 

include co-locating a health care needs 

coordinator within the medical practice, 

linking family members and other 

caregivers to support groups, coordinating 

a plan-of-care with the family and other 

39
service providers (including mental 

health and education), maintaining a 

central medical record or database of all 

pertinent medical information, facilitating 

referrals to other providers by assisting 

the family in communicating medical 

issues, and reviewing with the family the 

recommendations for care made by others. 

•	 Approaching service delivery from a 

family-centered perspective. Traditionally, 

medical practitioners (as well as mental 

health and substance abuse providers) 

adopt the view that services need to 

be targeted to the “identified patient.” 

Moving from individual-centered care 

to serving the family as a whole requires 

that the health and well-being of children 

be considered with the context of their 

families and other important relationships. 

This includes attention to the mental health 

and substance abuse needs of parents and 

other caregivers. Providing this level of 

care means that primary care physicians 

need to have training and tools for 

assessing the range of a family’s strengths 

and risks that may have an impact on a 

child’s development. Accordingly, this 

requires changes in the way providers 

initially are trained, how they receive 

continuing education, and how office staff 

members are trained. 

•	 Ensuring that designated office staff 

members develop strong working 

relationships with other service providers.

Critical factors needed to ensure that 

families are connected with appropriate 

services include staff member awareness of 

which providers are taking new clients, the 

availability of culturally appropriate and 

bilingual services, hours of operation, and 

types of health insurance plans accepted.

•	 Co-locating a variety of services and 

supports within the primary care office, 

when feasible. Having mental health 

services onsite increases accessibility 

and the likelihood of use and, in some 

cases, may help to reduce the stigma often 

associated with receipt of mental health 

services.

Schools offer another common and accessible 

venue for engaging families in need. The 

transition from home to school is a strategic 

time to begin early interventions because 

this time can be stressful for parents and 

caregivers and children.101 During such periods 

of transition, a parent or caregiver who may 

otherwise be reluctant to participate in school 

activities may be more open to interventions 

that support their parenting efforts. 

School settings present a key opportunity to 

promote mental wellness and prevent mental 

health problems among all children. More 

than 52 million students attend more than 

114,000 schools in the United States. When 

combined with the 6 million adults working at 

those schools, almost one-fifth of the Nation’s 

population passes through our schools on any 

given weekday.102 Children of all economic, 

geographic, and racial and cultural groups 

have equal access to a public education. 

According to a new national survey released 

in 2005 by SAMHSA, one-fifth of students 

receive some type of school-supported mental 

health services during the school year.103 The 

advantage to school-based interventions is that 

they teach children social and emotional skills 

while they also support academic achievement. 

Illinois already is acting on the recognized 

and crucial link between a child’s social and 

emotional growth and his or her potential to 

achieve academically and in life. In 2003, 

Illinois passed the Children’s Mental Health 

Act, with the intent that schools take concrete 

40
steps to address the social and emotional 

learning of students. The following year, the 

Illinois State Board of Education adopted 

social and emotional learning standards as 

part of the core curriculum. Standards and 

developmental benchmarks are established 

for all school children, from kindergarten 

through 12th grade. The goals set by Illinois 

for social-emotional learning are for children 

to:

• Develop self-awareness and selfmanagement skills to achieve school and 

life success. 

• Use social-awareness and interpersonal 

skills to establish and maintain positive 

relationships.

• Demonstrate decision-making skills and 

responsible behaviors in personal, school, 

and community contexts.

Illinois set a national precedent for a 

widespread, proactive approach to children’s 

mental health. New York State is following 

its lead. In September 2006, the governor 

signed into law the Children’s Mental 

Health Act of 2006. This act directs the 

commissioners of education and mental 

health to cooperatively establish a children’s 

mental health plan to provide comprehensive 

prevention, early intervention, and treatment 

services for children through age 18. Similar 

to the Illinois legislation, the act calls for 

the integration of social and emotional 

development into elementary and secondary 

school educational standards. 

Considering Culture When Working 

With Parents and Other Caregivers 

Many experts believe that prevention programs 

are most effective when they are tailored to 

the cultural, community, and developmental 

norms of program participants. 104–105 Culture, 

defined as a common heritage or set of shared 

beliefs, norms, and values, has profound 

implications for what individuals bring to a 

community, school, or clinic setting. Culture 

can determine whether people seek help, 

what types of help they seek, what coping 

styles and social supports they have, and how 

much stigma they attach to mental health 

problems. It can account for variations in how 

individuals communicate their symptoms and 

which ones they report. 

When service providers are not sensitive 

to cultural variations in family structure, 

coping style, and problem expression, their 

interventions may be met with resistance.106 

Failure to understand the forces that help 

shape an individual’s and a culture’s 

identity can derail a program. Culturally 

competent programs and services incorporate 

understanding of racial and ethnic groups, 

their histories, traditions, beliefs, and value 

systems.107–108

Identifying Opportunities That 

Support Implementation of Promotion 

and Prevention Practices

Research and practice consistently document 

the value of providing children with a secure 

foundation in which to grow to their full 

potential socially, emotionally, academically, 

and professionally. As a result, a variety 

of agencies at the Federal, State, and local 

government levels are involved in efforts to 

expand the use of promotion and prevention 

practices. The rationale for this broad-based 

involvement is that these agencies can better 

achieve their own missions and mandates by 

promoting the mental health of children and 

by preventing the onset or exacerbation of 

emotional and behavior problems that place 

the children at risk of developing mental 

illnesses. The examples that follow are just 

4411
42

a sample of available Federal programs that 

emphasize a public health approach to mental 

health. 

The Safe Schools/Healthy Students (SS/HS) 

program is administered jointly by the U.S. 

Departments of Health and Human Services 

(DHHS), Education, and Justice. Begun 

in 1999, SS/HS grants have funded local 

education, mental health, law enforcement, 

and juvenile justice partnerships in 220 

communities and in nearly every State. In July 

2006, more than $31 million was awarded 

to 19 school districts in 14 States. Under 

the initiative, school districts in partnership 

with local law enforcement, juvenile justice, 

and mental health agencies implement a 

comprehensive plan focused on safe school 

environments, mental health services, and 

early childhood socio-emotional development 

programs. To support implementation efforts, 

DHHS, through SAMHSA’s Center for Mental 

Health Services, supports the National Center 

for Mental Health Promotion and Youth 

Violence Prevention (www.promoteprevent.

org). Community interest in the grant program 

is high—the highly competitive program 

attracted 485 applications nationally in 2006. 

Current grants are awarded under the No Child 

Left Behind Act. 

The U.S. Department of Education administers 

a program entitled 21st Century Community 

Learning Centers, which also is authorized 

under the No Child Left Behind Act. Each 

year, the U.S. Department of Education awards 

57 formula grants to State education agencies, 

which in turn manage statewide competitions 

and award grants to eligible entities. This 

program provides expanded academic 

enrichment opportunities for children 

attending low-performing schools. However, 

due to the association between academic 

achievement and the emotional and behavior 

status of children, grant-funded activities 

include youth development programs, drug 

and violence prevention programs, and 

counseling and character education. To help 

support this program, the U.S. Department 

of Education funds the National Center for 

Early Development and Learning (www.fpg.

unc.edu/~ncedl/). Research by the center 

focuses on enhancing the cognitive, social and 

emotional development of children from birth 

through age 8. 

SAMHSA also awards State Incentive Grants 

annually to States and tribes to improve and 

expand services to individuals with or at risk 

of developing mental and substance abuse 

disorders. SAMHSA’s Center for Substance 

Abuse Prevention (CSAP) initiated the 

program in 2004 as a means of implementing 

a public health approach known as the 

Strategic Prevention Framework (SPF). SPF 

is a systematic effort that builds prevention 

capacity and infrastructure at the State and 

community levels. CSAP has 37 SPF State 

Incentive Grants in place which, to date, have 

reached more than 2 million adolescents with 

evidence-based substance use prevention 

efforts.

In 2004, the administration of the Drug-Free 

Communities (DFC) program was moved 

to CSAP from the White House Office of 

National Drug Control Policy. The DFC 

program provides grants of up to $100,000 

to community coalitions to prevent substance 

abuse by youth. Grant funding enables 

coalitions to strengthen their coordination 

and prevention efforts, encourage citizen 

participation in substance abuse reduction 

efforts, and disseminate information about 

effective programs. As noted earlier, there 

is an association between substance use and 

other mental health disorders. In studies of 

adolescents receiving mental health services, 
about half had a co-occurring substance use 

disorder. The study found that depression 

and conduct disorders were the most frequent 

mental disorders diagnosed in the presence of 

a co-occurring substance use disorder. This 

association strongly suggests that prevention 

of one may contribute to prevention and 

reduction of the other. 

Other opportunities to integrate early 

intervention and prevention practices into 

community-based mental health programs 

are offered through SAMHSA’s Center for 

Mental Health Services (CMHS). Maryland, 

for example, is using its State Incentive 

Grant for Mental Health Transformation to 

strengthen cross-agency collaboration in 

providing children and families with greater 

access to appropriate services. In addition, 

CMHS manages the State/Tribal Youth 

Suicide Prevention Grant Program, which 

supports the development and implementation 

of statewide or tribal youth suicide prevention 

and early intervention strategies. These grants 

are authorized by the Garrett Lee Smith 

Memorial Act. SAMHSA requires that the 

programs involve public/private collaboration 

and should include schools, educational 

institutions, juvenile justice systems, foster 

care systems, substance abuse and mental 

health programs, and other child and youth 

supporting organizations.

The Centers for Medicare and Medicaid 

Services (CMS) reimburse States for 

medically necessary and approved evidencebased services to children with diagnosable 

mental health disorders who are eligible 

for Medicaid. These may be seen as early 

intervention and prevention services insofar 

as they may prevent or reduce additional 

conditions and their consequences. States 

may exercise waivers and other options to 

cover these services. Medicaid, however, 

does not fund prevention programs per 

se. Therefore, it would not fund many of 

the prevention programs described in this 

document. 

43
44

• Responsibility for children’s mental health care is shared across multiple systems, 

including schools, primary health care, the juvenile justice system, child welfare, and 

substance abuse prevention and treatment. The first system, however, is the family.

• Parents and other caregivers should be recognized and supported as decision makers 

at the service delivery level, with respect to their own children. They also should have 

meaningful involvement at the system level in policymaking and planning, implementing, 

and evaluating programs and service systems. 

• The basic issue is not whether families are difficult to involve but rather how a 

community can make practices more accessible and culturally acceptable.

• Decision-making mechanisms and processes that include family members as equal 

participants need to be strengthened or created. Such mechanisms need to be 

accessible to family-member participation in terms of location, time, and language, 

and should include norms that convey parity in decision making and respect for the 

knowledge and experience that family members contribute to the decision-making 

process.

• Programs are most effective when they are tailored to the cultural, community, and 

developmental norms of program participants. Cultural adaptations promote relevancy 

and acceptance by racial and other underserved populations.

• Successful strategies include meeting families in environments that fit within the normal 

routine (e.g., home, work, primary care, and school life), integrating cultural strengths, 

and accommodating financial constraints. 

• Primary care is a natural point of contact for families and a place where a child’s mental 

health problem, as well as risk factors related to the onset of mental health problems, 

could be addressed openly as part of an overall discussion of health.

• School settings present a key opportunity to promote mental wellness among children. 

An advantage to school-based interventions is that they address the underlying causes 

of many behavior problems in children while also supporting academic achievement. 

• Many Federal, State, and local agencies and interests are involved in promoting 

the mental health of children and preventing the onset or exacerbation of emotional 

and behavior problems. This broad-based involvement demonstrates a public health 

approach to mental health and acknowledges that sound mental health in children helps 

to fulfill the mission and mandate of multiple service systems (e.g., education, justice, 

child welfare, and health).

Key Points from Section IV. Best Opportunities for Implementing 

Evidence-Based Practices To Reach Families in Need
Section V. Recommendations 

for Future Prevention Efforts

45

Rigorous evaluations of numerous 

programs indicate that effective 

interventions exist to promote 

mental wellness in children and 

reduce the risk of mental health 

and behavior problems. These interventions 

address the strengths and vulnerabilities of 

children from infancy through adolescence; 

across different cultural, racial, and ethnic 

groups; and across urban and rural settings. 

The majority of mental health problems 

begin during childhood and adolescence.109–110 

Consequently, effective promotion, prevention, 

and early intervention services that reduce the 

likelihood of problems in these populations 

are critical to the health of individuals and the 

Nation. In addition, they provide economic 

benefits across multiple systems. For the future 

health of our country, the mental wellness of 

our children must be a long-term, proactive, 

and collaborative priority. This is likely to 

happen only if greater emphasis is placed on a 

public health approach to mental health. 

Recommendations

This report recommends that—for the health 

and well-being of children, their families, and 

their communities—Federal, State, and local 

policymakers as well as child- and familyserving agencies and advocacy organizations 

should:
1

Support ways to communicate 

the good news of prevention, 

including the economic and social 

benefits of investing in prevention.

The good news is unequivocal—evidencebased promotion and prevention programs 

implemented with fidelity strengthen parenting 

and build child resilience. It is important 

that the benefits of mental health promotion 

and prevention programs be communicated 

broadly so that families and communities 

have information about what interventions 

work where and with what resources when 

considering what programs to implement. 

Creating opportunities for families and 

communities to understand how promotion 

and prevention programs fit within a broader 

public health context will also be helpful.

2

Provide family members, other 

caregivers, community leaders, 

and local educators with the latest 

knowledge for strengthening 

parenting and building child 

resilience so that informed 

decisions about appropriate 

interventions can be made easily. 

Web sites that provide easy access to 

information about evidence-based programs 

are an efficient mechanism for communicating 

with families and communities. Multiple webbased databases of evidence-based practices 

exist currently across the Federal government. 

For example, DHHS, U.S. Departments of 

Education and Justice, Centers for Disease 

Control and Prevention (CDC), and the 

National Institute on Drug Abuse (NIDA) 

maintain databases of model programs that 

address mental health risk and protective 

factors. First Lady Laura Bush also recently 

introduced the Helping America’s Youth 

(HAY) web site (www.helpingamericasyouth.

gov), in which the programs recognized 

as effective by nine Federal agencies are 

available as part of an integrated system to 

help communities build partnerships, assess 

needs and resources, and select relevant 

programs that could be implemented in their 

community.

The visibility that children’s promotion 

and prevention programs gain through 

multiple outlets has value. However, the 

preponderance of databases makes it difficult 

for communities to find and select the most 

appropriate programs. To maximize the use 

of Federal resources, it would be helpful 

to have a centralized, web-based database 

supported by all child- and family- serving 

Federal institutions. The database should be 

organized to identify evidence-based programs 

across developmental age groups, such as 

prenatal, infant, early childhood, child, youth, 

and adolescence. Additionally, it would 

be helpful for communities if the database 

provided information on when, and for whom, 

the intervention worked; what components of 

the intervention must be retained to ensure 

fidelity; ways to coordinate new programs 

so that they build on effective strategies that 

already are in place or are being introduced 

simultaneously; and the capacity and supports 

necessary to implement the intervention 

effectively. SAMHSA will launch a new 

NREPP web site early in 2007, which will 

provide a useful model. 

To achieve this recommendation, a study 

to identify opportunities to strengthen, 

coordinate, and consolidate the synthesis and 

dissemination of evidence on effective mental 

and substance abuse preventive interventions 

and services across Federal and private-

46
47

sector entities would be helpful. Entities 

to be involved would include SAMHSA; 

National Institute of Mental Health; NIDA; 

National Institute on Alcohol Abuse and 

Alcoholism; National Institute of Child 

Health and Human Development; Agency 

for Healthcare Research and Quality; U.S. 

Departments of Justice and Education; CDC; 

CMS; the Administration for Children, 

Youth, and Families; and States, professional 

associations, national mental health 

organizations, advocates, foundations, and 

other private-sector groups.

3

Where possible, build on existing 

programs to maximize available 

knowledge and resources.

The final report by the President’s New 

Freedom Commission on Mental Health 

points to the potential of Federal agencies 

to better serve children, families, and adults 

by better aligning funding and programs. 

Achieving this potential is increasingly 

important as the Federal government works 

to control the costs of health care. As an 

example, CMHS and CSAP could work 

together to expand the mission of regional 

Centers for the Application of Preventive 

Technologies (CAPT) to focus on mental 

health promotion, mental illness prevention, 

and alcohol and other drug prevention. CSAP 

already supports National CAPTs that assist 

States and other jurisdictions and communitybased organizations in applying the latest 

evidence-based knowledge to their substance 

abuse prevention programs, practices, and 

policies. Given that substance abuse and 

many other mental health problems share 

common risk factors, common technical 

assistance centers could expand expertise and 

maximized the use of existing resources. 

Federal agencies also should work to 

coordinate ongoing research into early 

intervention and prevention programs and 

the application and evaluation of these 

programs. A multi-departmental workgroup 

could be formed with a mission to improve 

the adoption and sustaining of evidence-based 

prevention programs. This initiative should 

coordinate the existing efforts of SAMHSA; 

NIMH; NIDA; National Institute on Alcohol 

Abuse and Alcoholism; CDC; Agency for 

Healthcare Research and Quality; CMS; 

Administration for Children and Families; 

U.S. Departments of Education, Labor, and 

Veterans Affairs; Health Resources and 

Services Administration; and the Office of 

Juvenile Justice and Delinquency Prevention. 

To further this goal, the senior administrators 

of the involved departments should develop 

and fund cross-agency efforts to improve the 

adoption and maintenance of evidence-based 

program.

4

Encourage the development of 

the State and local infrastructure 

necessary to adopt, adapt, 

implement, evaluate, improve, 

and sustain evidence-based 

practices.

Knowing which programs are effective is 

only a first step toward implementation. 

Communities also need to consider what 

systems and supports need to be in place to 

actually implement and sustain an evidencebased practice. Examples include:

•	 Structures for coordinated planning and 

program implementation across relevant 

child- and family-serving institutions 

and for involving families and other 

caregivers in this process. 
•	 Procedures for assessing community risk 

and protective factors, reviewing evidencebased practices, selecting those that are 

appropriate, developing implementation, 

evaluation, and sustainability plans, 

and using evaluation data for quality 

improvement.

•	 Information management systems for 

collecting, analyzing, and reporting of 

data, as well as tools to assess multiple 

social and mental health outcomes.

•	 Training and technical assistance systems 

to ensure that the workforce has the 

requisite skills to implement practices 

selected by the community.

•	 Supervision, coaching, and monitoring 

procedures to assure that evidence-based 

practices are implemented with fidelity.

A next step in successfully implementing 

evidence-based practices is to expand the 

knowledge base about what is necessary for 

programs to work in other settings and on a 

larger scale. Replication of evidence-based 

practices requires documentation of the 

systems and supports needed for effective 

implementation. This information is critical to 

bringing programs to scale, such as effectively 

transforming a program that is successful 

within one school to being successful within 

all schools within a community. 

Similarly, this same information is critical 

when adapting practices to populations other 

than the original target group. Successful 

adaptations must integrate the cultural, 

community, and developmental norms of 

a community while also adhering to the 

basic program characteristics that make the 

program effective. The SAMHSA/CMHS 

Prevention and Early Intervention grant 

program provides several illustrations of how 

some communities have adapted practices. 

For example, the highly regarded PATHS 

program as originally conceived did not have 

a component for family members. Working 

closely with Dr. Mark Greenberg, the program 

developer, a SAMHSA grantee in Harrisburg, 

PA, developed and tested a family resource kit 

for family members to “learn the language” of 

the PATHS program through games the family 

could play together. Similarly, a SAMHSA 

grantee in Yakima, WA, worked closely 

with Dr. David Olds to integrate a mental 

health component within the Nurse–Family 

Partnership program. 

5

Encourage a coordinated 

assessment and accountability 

system for promotion, prevention, 

and treatment in children’s mental 

health.

A community could have a better picture 

of the benefits and costs of its program if 

all relevant systems (e.g., mental health, 

substance abuse, education, and justice) could 

be consistent and coordinated in some of the 

data they collect, analyze, and report. For 

example, schools, which are a primary context 

for many evidence-based programs, especially 

need a system that coordinates evaluation 

of school-based promotion and prevention 

programs from preschool through high school. 

This system might include assessments of: 1) 

risk and protective factors, 2) implementation 

of interventions, and 3) multiple mental health 

and other outcomes (e.g., social, emotional, 

behavior, academic performance, and truancy). 

If the local juvenile justice system had a 

comparable system, it could coordinate with 

the educational system to assess overall social, 

emotional, and behavioral outcomes and the 

program’s economic impact on both systems.

Additionally, State governments could require 

that programs implemented with State funds 

48
49

in schools and other settings include an 

evaluation component. Federal and State 

Departments of Education could develop 

policies that establish accountability for 

fostering the full development of children, 

support professional development of 

educators to enable them to implement 

programs effectively, and create systems 

for assessing and evaluating program 

implementation and outcomes and for 

sustaining programs that are effective. 

6

Examine more systematic 

strategies to increase and 

coordinate funding for prevention 

efforts across Federal and/or 

State agencies.

The primary mechanism for moving 

evidence-based programs into communities 

has been grant programs sponsored by 

various Federal and State agencies, and 

usually those responsible for mental health 

(including substance abuse), education, or 

juvenile justice. Responsibility for children’s 

mental health care, however, is shared across 

multiple systems, including primary health 

care, and child welfare as well as mental 

health, education, and juvenile justice. Many 

of these systems independently conduct 

child- and family-based programs, even 

though programs goals may be the same. 

Better coordination of programs across 

systems could maximize the use of available 

resources. SAMHSA’s Strategic Prevention 

Framework provides a useful model for how 

communities can implement a coordinated 

system of services and programs more 

effectively. 

Another funding consideration is that the 

current reimbursement system for mental 

health care is set up to pay for individualized 

treatment services following the diagnosis

of a disorder. Prevention programs, on 

the other hand, generally are offered to a 

sizable population with a goal to prevent

diagnosable disorders from ever occurring. 

Exploring alternative methods for funding 

prevention programs would be beneficial. 

Some communities have funded promotion 

and prevention programs as part of standard 

budget allocations. The city of Hartford, 

CT, for example, partially funds its Student–

Family Assistance Centers through the school 

district budget. Other programs created and 

implemented under the SS/HS grant specific 

to preventing school and gang violence have 

been adopted by the mayor and now are part 

of the city’s budget.

A more systematic examination of strategies 

to coordinate funding mechanisms across 

agencies would be helpful, including the 

contributions and limitations of categorical 

prevention funding; the advantages and 

challenges of coordinated prevention 

and youth development programs; and 

strategies to design policies, programs, 

and accountability systems that coordinate 

prevention and promotion practices.

7

Build a workforce capable of 

implementing age- and culturally 

appropriate evidence-based 

practices effectively.

Workforce capacity-building is critical to 

meet current needs as well as to prepare 

for the demands of the future. The shortage 

of mental health professionals trained 

in promotion and prevention is a part 

of the overall shortage of mental health 

professionals in general. These shortages 

exist in many areas of the country, and 
50

Safe Schools/Healthy Students: Building a Collaborative Infrastructure for 

Program Success

In 2003, the Hartford (Connecticut) Public Schools District was awarded a 3-year, $8.4-million 

Safe Schools/Healthy Students (SS/HS) grant. According to Leah O’Neill Fichtner, SS/HS program 

coordinator, “Our children were running the risk of dropping out of school and continuing an 

intergenerational cycle of poverty, crime, violence, and self-destructive activity.”

The SS/HS grant served as a catalyst for the school system and community partners to develop and 

expand the capacity of community-based services by creating a service delivery system that integrates 

multiple resources across the city. Hartford Public Schools superintendent Robert Henry observed, “The 

SS/HS grant allowed us to work with our community and families, evaluate what is already in place, 

and develop new partnerships and programs to fill gaps. We also needed the infrastructure that would 

provide early identification of at-risk children and would connect youth and their families to appropriate 

mental health services and support programs.” 

An important part of this infrastructure is the Student and Family Assistance Centers that have been 

created across the city. These centers, centrally located in neighborhood schools, provide direct 

services or referral services for children and families. Instead of families having to find supportive 

services on their own, the centers provide them with a central, easy-to-locate access point to connect 

them with the resources they need. In the 2004-2005 academic year, 1,726 students were served in six 

Student and Family Assistance Centers, resulting in improved attendance and grades for some of the 

students. 

Additionally, Hartford’s SS/HS initiative supported the development of a web-based case management 

system called “Hartford Connects,” which links data from multiple settings: schools, neighborhoods, 

and judicial and health environments. Data are analyzed to identify needs so that program resources 

can be adjusted to address emerging problems best. Hartford’s Mayor, Eddie Perez, sees the Hartford 

Connects system as the foundation of the development of a city-wide coordinated support system for all 

children and youth.
particularly in rural areas. In addition, 

severe shortages exist for providers who are 

culturally and linguistically competent to 

serve racial/ethnic minority populations. 

SAMHSA has begun to address the challenge 

of workforce shortages through its National 

Strategic Workforce Development Plan to 

Reduce Mental Health Disparities. The goal 

of this effort is to expand and improve the 

capacity of the mental health workforce to 

meet the needs of racial and ethnic minority 

consumers, children, and families; to address 

the concerns of rural consumers and family 

members; to make consistent and appropriate 

use of evidence-based interventions; and to 

work at the interface of primary and mental 

health care settings. 

Developing a workforce capable of 

implementing age-appropriate, evidencebased promotion and prevention practices 

now and in the future requires both training 

of a new workforce and retraining of the 

existing workforce. The key to the quality 

of an intervention program is fidelity, 

and desirable outcomes for children and 

families are achieved only when effective 

intervention programs are implemented with 

fidelity.111–113 Fidelity can be compromised 

when inadequately trained personnel alter 

the content, duration, or structure of a 

program. If an implementer wants to adapt a 

program to achieve cultural appropriateness 

or for any other reason, he or she must work 

with the program’s developer to ensure that 

the adaptations do not pose a threat to the 

integrity of the program.

Institutions of higher education, boards 

that license mental health professionals, 

professional associations, and reimbursement 

agencies should work together to ensure 

the continuing education and certification 

of individual practitioners across a variety 

of effective, evidence-based promotion and 

prevention programs and practices. Enacting 

these measures will continue to move systems 

forward in implementing evidence-based 

programs and ensuring that these efforts are 

carried out with sufficient fidelity and rigor to 

ensure continued effectiveness.

To promote the expansion of the knowledge 

base, workforce development should include 

the development of future researchers. This 

involves undergraduate, master, doctoral, 

postdoctoral, and mid-career training to 

ensure researchers who are equipped to 

design and evaluate culturally competent 

prevention and promotion programs. The 

NIMH-sponsored doctoral and postdoctoral 

training programs in Prevention Research 

and Children’s Mental Health Services 

Research are examples of positive steps in 

this direction.

Finally, it will also be important for our 

future workforce to understand the public 

health approach and the importance and 

effectiveness of promotion and prevention 

across service systems.

8

Include families in a decisionmaking role from the outset; that 

is, in the planning, selection, 

adaptation, implementation, 

evaluation, and sustaining of 

programs for their children and 

their communities.

Family involvement is essential to the 

acceptance, effective implementation, 

and refinement of interventions for 

children. Family-driven approaches can 

increase positive results by expanding the 

51
environments in which the program takes 

place. For example, the Strengthening 

Families Program involves elementary schoolaged children and their families in family 

skills training sessions. An evaluation study 

of program outcomes indicated reductions in 

child aggression and conduct problems that 

averaged 10 times greater than those produced 

by school-based, child-only preventive 

interventions. 

Agencies and schools serving children and 

their families should develop methods to 

educate, encourage, and empower families to 

be informed decision makers in expanding the 

use of evidence-based practices. To this end:

•	 Program administrators and staff 

members should be trained and supported 

in creating family-driven approaches 

to family involvement and program 

planning, implementation, monitoring, and 

evaluation.

•	 Schools should create and support schoolfamily partnerships with identified 

school-family liaison personnel. These 

partnerships should work toward the 

development and ongoing implementation 

of widespread programs to support 

children’s social, emotional, and academic 

learning.

52
Broad-based recommendations for Federal, State, and local collaboration to advance 

promotion and prevention programs for children’s mental health are to:

1. Communicate the good news of prevention, including the economic and social benefits 

of investing in prevention. 

2. Provide family members, other caregivers, community leaders, and local educators 

with the latest knowledge for strengthening parenting and building child resilience so 

informed decisions about appropriate interventions can be made easily. 

3. Build on existing programs to maximize available knowledge and resources.

4. Encourage the development of the State and local infrastructure necessary to adopt, 

adapt, implement, evaluate, improve, and sustain evidence-based practices.

5. Encourage a coordinated assessment and accountability system for promotion, 

prevention, and treatment in children’s mental health.

6. Examine more systematic strategies to increase and coordinate funding for prevention 

efforts across Federal and State agencies.

7. Build a workforce capable of implementing age- and culturally- appropriate evidencebased practices effectively.

8. Include families in a decision-making role from the outset; that is, in the planning, 

selection, adaptation, implementation, evaluation, and sustaining of programs for their 

children and their communities.

Key Points from Section V. Recommendations for 

Future Prevention Efforts 

53

The future of children’s mental 

health care holds great 

promise. Not only do many 

evidence-based resiliencebuilding prevention programs 

exist, but more are being developed as the 

need for and the value of these programs 

becomes more apparent. In addition, 

researchers and implementers increasingly 

are working together to ensure fidelity 

of implementation, even while making 

appropriate adaptations for cultural, age, 

gender, and situational appropriateness. 

Available cost-benefit data for the 

programs confirm their worth. Numerous 

analyses have identified promotion and 

prevention programs that more than pay 

for themselves, with substantial immediate 

and long-term benefits accruing both to 

individuals and to their communities. The 

technology that could make a substantial 

positive contribution to promoting the 

mental health of children is available and 

expanding. Government agencies at all 

levels are working to create databases 

of information about programs and their 

effectiveness and are offering tools to aid 

implementation. 

Promotion and prevention programs for 

children work! Research and practice 

indicate which programs work best and for 

which populations. The critical next step is 

for more communities to become aware of 

these programs and to begin implementing 

them, even while researchers continue to 

expand the knowledge base about what 

interventions work and why they work. 

Children’s mental health is the foundation 

on which they build their adult life. It 

is up to policy makers, in concert with 

parents and others who can help influence 

the outcome, to ensure that children have 

every opportunity to achieve the mental 

health status that will enable them to be 

successful, contributing members of their 

families, their communities, and their 

Nation. 

Conclusion

55

Charlotte Ball

Senior Writer

Macro International Inc.

Rockville, MD

Jacqueline Bruce, Ph.D. 

Research Associate

Oregon Social Learning Center

Eugene, OR

Center for Mental Health Services

Substance Abuse and Mental Health Services 

Administration

Rockville, MD

David S. DeGarmo, Ph.D. 

Research Scientist

Oregon Social Learning Center

Eugene, OR

Edward G. Feil, Ph.D.

Research Scientist

Oregon Research Institute

Eugene, OR

Philip A. Fisher, Ph.D. 

Research Scientist

Oregon Social Learning Center

Senior Research Scientist

Center for Research to Practice

Eugene, OR

Health and Human Development Programs

Education Development Center, Inc.

Newton, MA

Sheppard G. Kellam, M.D.

Senior Research Fellow

American Institutes for Research

Washington, DC

John A. Landsverk, Ph.D.

Director

Child and Adolescent Services Research Center San 

Diego State University

San Diego, CA

Leslie D. Leve, Ph.D. 

Research Scientist

Oregon Social Learning Center

Eugene, OR 

Philip J. Leaf, Ph.D. 

Director

Center for the Prevention of Youth Violence

Professor

Department of Mental Health

Bloomberg School of Public Health

Johns Hopkins University

Baltimore, MD

David Osher, Ph.D.

Managing Director

American Institutes for Research

Washington, DC

Katherine C. Pears, Ph.D. 

Research Scientist

Oregon Social Learning Center

Eugene, OR

John B. Reid, Ph.D. 

Research Scientist

Oregon Social Learning Center 

Senior Research Scientist

Center for Research to Practice

Eugene, OR

Daniel S. Shaw, Ph.D.

Director

Pitt Early Steps Project

University of Pittsburgh 

Pittsburgh, PA

Roger P. Weissberg, Ph.D. 

President

Collaborative for Academic, Social and 

Emotional Learning (CASEL)

Professor

Department of Psychology

University of Illinois at Chicago

Chicago, IL

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