1. MHA Webinar Presentation by William R. Beardslee, MD Department of Psychiatry Children’s Hospital Boston Harvard Medical School 20 April 2011 “Prevention of Mental Health Conditions and Depression in Parenting: Implications of Two Recent IOM Reports”

2. Committee Charge Review promising areas of research Highlight areas of key advances and persistent challenges Examine the research base within a developmental framework Review the current scope of federal efforts Recommend areas of emphasis for future federal policies and programs of research

3. Committee Members KENNETH WARNER (Chair), School of Public Health, University of Michigan THOMAS BOAT (Vice Chair), Cincinnati Children’s Hospital Medical Center WILLIAM R. BEARDSLEE, Department of Psychiatry, Children’s Hospital Boston CARL C. BELL, University of Illinois at Chicago, Community Mental Health Council ANTHONY BIGLAN, Center on Early Adolescence, Oregon Research Institute C. HENDRICKS BROWN, College of Public Health, University of South Florida E. JANE COSTELLO, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center TERESA D. LaFROMBOISE, School of Education, Stanford University RICARDO F. MUNOZ, Department of Psychiatry, University of California, San Francisco PETER J. PECORA, Casey Family Programs and School of Social Work, University of Washington BRADLEY S. PETERSON, Pediatric Neuropsychiatry, Columbia University LINDA A. RANDOLPH, Developing Families Center, Washington, DC IRWIN SANDLER, Prevention Research Center, Arizona State University MARY ELLEN O’CONNELL, Study Director

4. On Behalf of the Committee … Thank You

5. Disorders Are Common and Costly Around 1 in 5 young people (14-20%) have a current disorder Estimated $247 billion in annual costs Costs to multiple sectors – education, justice, health care, social welfare Costs to the individual and family

6. Preventive Opportunities Early in Life Early onset 50% of adult disorders had onset by age 14 75% by age 24 First symptoms occur 2-4 years prior to diagnosable disorder Common risk factors for multiple problems and disorders Sound understanding of protective factors and resiliency

7. Key Core Concepts of Prevention  Prevention requires a paradigm shift  Mental health and physical health are inseparable  Successful prevention is inherently interdisciplinary  Mental, emotional, and behavioral disorders are developmental  Coordinated community level systems are needed to support young people  Developmental perspective is key

8. Prevention Window

9. Defining Prevention and Promotion Prevention should not include the preventive aspects of treatment Prevention and promotion overlap, but promotion has important distinct role Mental health not just the absence of disorder

10. Prevention AND Promotion

11. Mental Health Promotion Aims to: Enhance individuals’ ability to achieve developmentally appropriate tasks (developmental competence) positive sense of self-esteem, mastery, well- being, and social inclusion Strengthen their ability to cope with adversity

12. Preventive Intervention Opportunities

13. Evidence that Some Disorders Can be Prevented Risk and protective factors focus of research Interventions tied to factors Multi-year effects on substance abuse, conduct disorder, antisocial behavior, aggression and child maltreatment

14. Evidence that Some Disorders Can be Prevented (cont’d) Indications that incidence of adolescent depression can be reduced Interventions that target family adversity reduce depression risk and increase effective parenting Emerging evidence for schizophrenia

15. Evidence of School-related Effects School-based violence prevention can reduce aggressive problems by one- quarter to one-third Social and emotional learning programs may improve academic outcomes Promising but limited benefit-cost information

16. Citation Hawkins JD, Kosterman R, Catalano RF, Hill KG, and Abbott RD. Effects of Social Development Intervention in Childhood 15 Years Later. Arch Pediatr Adolesc Med. 162(12), pp 1133-1141, 2008. Teacher training in classroom instruction and management, child social and emotional skill development and parent workshops were the intervention. A significant multi-varied effect across all 16 primary outcome indices were found. Specific effects included significantly better educational and economic attainment, mental health and sexual health by age 27 years (all P<.05). So prevention is possible.

17. Program Examples with Multiple Outcomes Parenting Programs (Incredible Years, Triple P, Strengthening Families Program) Comprehensive Early Education Family Disruption Interventions (e.g., Divorce, Maternal Depression) School-Based Programs

18. Implementation Need to move from efficacy toward effectiveness trials Implementation research has highlighted: complexity important role of community

19. Implementation Approaches Implement specific evidence-based programs Adapt (and evaluate) evidence-based program to community needs Develop and test community-driven models

20. Screening Screening should meet modified WHO criteria Validated tool Responsive to community priorities Intervention available Parent endorsement

21. Opportunities for Linkages with Neuroscience Interactions between modifiable environmental factors and expression of genes linked to behavior Greater understanding of biological processes of brain development Opportunities for integration of genetics and neuroscience research with prevention research

22. A Central Theme “The scientific foundation has been created for the nation to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships with others.”

23. Continuing a Course of Rigorous Research:Overarching Recommendations NIH should develop comprehensive 10- year prevention and promotion research plan Research funders should establish parity between research on preventive interventions and treatment interventions

24. Mental Health America We need a “national initiative to advance the use of prevention and promotion approaches to benefit the mental health of the nation’s young people. There is no national program, like the physical fitness initiative of the 60’s, to ensure that every child maximizes his or her capacity”

25. Recommendation Themes Putting Knowledge into Practice Continuing Course of Rigorous Research

26. Quotation “One factor lurks in the background of every discussion of the risks for mental, emotional, and behavioral disorders and antisocial behavior: poverty... Although not the focus of this report, there is evidence that changes in social policy that reduce exposure to these risks are at least as important for preventing mental, emotional and behavioral disorders in young people as other preventive interventions. We are persuaded that the future mental health of the nation depends crucially on how, collectively, the costly legacy of poverty is dealt with.”

27. Putting Knowledge Into Practice: Overarching Recommendations Make healthy mental, emotional, and behavioral development a national priority Establish public prevention goals White House should establish ongoing multi- agency strategic planning mechanism Align federal resources with strategy States and communities should develop networked systems

28. Putting Knowledge Into Practice: Funding Prevention set-aside in mental health block grant Braided funding Fund state, county, and local prevention and promotion networks

29. Putting Knowledge Into Practice: Funding (Cont’d) Target resources to communities with elevated risk factors Facilitate researcher-community partnerships Prioritize use of evidence-based programs and promote rigorous evaluation across range of settings

30. Continuing a Course of Rigorous Research:Overarching Recommendations NIH should develop comprehensive 10- year prevention and promotion research plan Research funders should establish parity between research on preventive interventions and treatment interventions

31. Continuing a Course of Rigorous Research: 10-Year Priorities Prevention (specific disorders and common risk factors) and promotion Replication, long-term outcomes, and multiple groups Collaborations across institutes and agencies for developmentally related outcomes Further improve current interventions

32. Continuing a Course of Rigorous Research: 10-Year Priorities (Cont’d) Guidelines and funding for economic analyses Etiology and measurement of developmental competencies Effectiveness of mass media and internet interventions Address research gaps in populations and settings

33. To read more about project and view the full report, a 4-page report brief, and this presentation: http://www.bocyf.org/parental_depression.html

34. Committee on Depression, Parenting Practices, and the Healthy Development of Children Study Charge Parenting Practices Depression in Parents Development of Children “To review the relevant research literature on the identification, prevention, and treatment of parental depression, its interaction with parenting practices, and its effects on children and families.”

35. Prevalence of Depression Depression is a prevalent and impairing problem Affects 20% of adults in their lifetime Disparities in prevalence rates in adults Age, ethnicity, sex, and marital status Many adults are parents Similar rates, disparities 7.5 million parents are affected by depression each year

36. Impact of Depression Depression leads to sustained individual, family, and societal costs Specifically for parents, depression can –Interfere with parenting quality –Put children at risk for poor health and development at all ages At least 15.6 million children live with an adult who had major depression in the past year

37. Treatment: Current Evidence A variety of safe and effective tools exist for treating adults with elevated symptoms or major depression A variety of strategies to deliver these treatments exist in a wide range of settings Specifically for parents, evidence on the safety and efficacy of treatment tools and strategies generally DO NOT: Target parents Measure its impact on parental functioning or its effects on child outcomes (except during pregnancy and for mothers postpartum)

38. Treatment: Current Evidence, continued. Individuals should have informed choices in treatment “tools” that are available to them Treatment tools and strategies to deliver these treatments should be flexible, efficient, inexpensive, and above all acceptable to the participants in a wide variety of community and clinical settings

39. Prevention: Current Evidence Emerging prevention interventions for families with depressed parents or adaptations of other existing evidence-based parenting and child development interventions demonstrate promise for improving outcomes in these families –Prevent or improve depression in the parent –Target vulnerabilities of children of depressed parents –Improve parent-child relationships –Use two-generation approach Broader prevention interventions that support families and the healthy development of children also hold promise A variety of prevention programs are effective in low-income families and from varied culturally and linguistic backgrounds

40. Depression Prevention as an Outcome of Another Intervention 1. Rick Price and colleagues, University of Michigan, Jobs Program – Jobs retraining for unemployment 2. Irwin Sandler and colleagues, Bereavement Program for those undergoing parental loss 3. Early Head Start Each helps individuals and families accomplish age- appropriate developmental tasks and embeds prevention and treatment in larger systems that foster these.

41. Depression Prevention Examples 1. Family Talk - Beardslee, et al., 2009 2. Prevention of depression - Garber, et al., 2009 3. Parent/Child Coping Session - Compas et al., in press. 4. Parental bereavement - Sandler 5. Home visitation – Putnam 6. The Incredible Years – Webster-Stratton 7. Early Head Start – parental depression 8. Mothers’ and babies’ program - Munoz

42. Seven Different Implementations of Family Depression Approach 1. Randomized trial pilot – Dorchester for single parent families of color 2. Development of a program for Latino families 3. Large scale approaches – collaborations in Finland and Norway 4. Head Start – Program for parental adversity / depression 5. Blackfeet Nation – Head Start 6. Costa Rica 7. Collaboration with other investigators in new preventive interventions; Project Focus

43. Commonalities Across Studies With Efficacy Trial Data 1. Strong theoretical orientation with an emphasis on cognitive changes 2. An orientation to strength-building and enhancement of protective factors 3. Manualized approaches with careful training 4. Strategies for selection of indicated groups at high risk

44. Critical Features of Care for Parents with Depression Integrative Comprehensive Multigenerational

45. Critical Features of Care for Parents with Depression, continued Developmentally Appropriate Available Across Settings Accessible Culturally Sensitive

46. Implementation and Disseminating Emerging initiatives highlight opportunities and challenges in improving the engagement and delivery of care to diverse families with a depressed parent Community, state, federal, and international level-initiatives A wide range of settings offer opportunities to engage and deliver care to diverse families with a depressed parent  Multiple challenges exist in implementing and disseminating innovative strategies Systemic Provider Capability Financial

47. Envisioning the Future 1. Factors shown to improve the physical and mental health of children are addressed and enhanced by the systems that provide services to them. 2. Families and children have ready access to the best available evidence-based preventive interventions delivered in their own communities in a culturally competent and respectful (nonstigmatizing way). 3. Preventive interventions are provided as a routine component of school, health, and community service systems. 4. A well organized public health monitoring system is in play to track the incidence of prevalence of MEB disorders and used to appropriately direct resources. 5. Services are coordinated and integrated with multiple points of entry for children and their families (e.g., schools, health care settings, and youth centers).

48. Envisioning the Future (continued) 6. As new preventive interventions are developed, they are rapidly deployed in multiple systems. 7. Families are informed that they have access to resources when they need them without barriers of culture, cost, or type of service. 7. Families and communities are partners in the development and implementation of preventive interventions. 8. The development and application of preventive intervention strategies contribute to narrowing rather than widening health disparities. 9. Teachers, child care workers, health care providers, and others are routinely trained on approaches to support the behavioral and emotional health of young people and the prevention of MEB disorders.

49. Additional Information Report available at: http://www.nap.eduhttp://www.nap.edu Summary available as free download Report briefs being developed March 25 dissemination event Webcast of event to be posted on web

50. References 1.Beardslee WR, Wright EJ, Gladstone TRG, and Forbes P. Long-term effects from a randomized trial of two public health preventive interventions for parental depression. J Family Psychol, 2008, 21, 703- 713. 2.Beardslee WR, Ayoub C, Avery MW, Watts CI, and O’Carroll KL. Family Connections: An approach for strengthening early care systems in facing depression and adversity. Am J Orthopsychiatry. 2010, 80(4), 482-95. 3.Children’s Hospital Boston Family Connections: A Comprehensive Approach in Dealing with Parental Depression and Related Adversities. (Materials in English and Spanish.) 2009. [On line] http://www.childrenshospital.org/clinicalservices/Site2684/mainpageS2 684P22.html.

51. References (continued) 4.D’Angelo EJ, Llerena-Quinn R, Shapiro R, Colon F, Gallagher K, and Beardslee WR. Adaptation of the Preventive Intervention Program for Depression for use with Latino Families. Fam Process, In Press. 5.Hawkins JD, Kosterman R, Catalano RF, Hill KG, and Abbott RD. Effects of Social Development Intervention in Childhood 15 Years Later. Arch Pediatr Adolesc Med. 162(12), pp 1133-1141, 2008. 6.Munoz RF, Cuijpers P, Smith F, Barrera AZ, and Leykin Y. Prevention of Major Depression. Annu Rev Clin Psychol, 2010, 6, 181-212.

52. References (continued) 7.National Research Council and Institute of Medicine. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Committee on Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. Mary Ellen O’Connell, Thomas Boat, and Kenneth E. Warner, Editors. Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press. 2009. [available on-line at http://www.nap.edu].

53. References (continued) 8.National Research Council and Institute of Medicine. Depression in parents, parenting and children: Opportunities to improve identification, treatment, and prevention efforts. Washington, DC: The National Academies Press. 2009. [On line] http://www.nap.du/catalog.php?record_id=12565. 9.Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, and Lutzker JR. Population-Based Prevention of Child Maltreatment: The U.S. Triple P System Population Trial. Prev Sci, 10:1-12, 2009.