MHA Webinar Presentation by

William R. Beardslee, MD Department of PsychiatryChildren’s Hospital Boston

Harvard Medical School20 April 2011

“Prevention of Mental Health Conditions and Depression in Parenting: Implications of Two Recent IOM Reports”

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

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

On Behalf of the Committee … Thank You

33

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

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

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

Prevention Window

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

Prevention AND Promotion

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

Preventive Intervention Opportunities

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

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

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

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.

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

Implementation

Need to move from efficacy toward effectiveness trials

Implementation research has highlighted: • complexity

• important role of community

Implementation Approaches

Implement specific evidence-based programs

Adapt (and evaluate) evidence-based program to community needs

Develop and test community-driven models

Screening

Screening should meet modified WHO criteria

Validated tool Responsive to community priorities Intervention available Parent endorsement

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

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.”

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

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”

Recommendation Themes

Putting Knowledge into Practice

Continuing Course of Rigorous Research

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.”

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

Putting Knowledge Into Practice: Funding

Prevention set-aside in mental health block grant

Braided funding

Fund state, county, and local prevention and promotion networks

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

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

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

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

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

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.”

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

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

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)

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

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

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.

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

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

Commonalities Across StudiesWith 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

Critical Features of Care for Parents with Depression

Integrative

Comprehensive

Multigenerational

Critical Features of Care for Parents with Depression, continued

Developmentally Appropriate

Available Across Settings

Accessible

Culturally Sensitive

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

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).

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.

Additional Information

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

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/mainpageS2684P22.html.

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.

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].

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.