“Prevention of Mental Health Conditions and
Depression in Parenting: Implications of Two
Recent IOM Reports”
MHA Webinar
Presentation by
William R. Beardslee, MD
Department of Psychiatry
Children’s Hospital Boston
Harvard Medical School
20 April 2011
Committee Charge
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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
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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
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MARY ELLEN O’CONNELL, Study Director
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On Behalf of the Committee …
Thank You
3
Disorders Are Common and Costly
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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
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Early onset
• 50% of adult disorders had onset by age 14
• 75% by age 24
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First symptoms occur 2-4 years prior to diagnosable
disorder
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Common risk factors for multiple problems and
disorders
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Sound understanding of protective factors and resiliency
Key Core Concepts of Prevention
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Prevention requires a paradigm shift
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Mental health and physical health are inseparable
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Successful prevention is inherently interdisciplinary
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Mental, emotional, and behavioral disorders are
developmental
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Coordinated community level systems are needed
to support young people
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Developmental perspective is key
Prevention Window
Defining Prevention and
Promotion
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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:
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Enhance individuals’
• ability to achieve developmentally appropriate
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tasks (developmental competence)
positive sense of self-esteem, mastery, wellbeing, and social inclusion
Strengthen their ability to cope with
adversity
Preventive Intervention Opportunities
Evidence that Some Disorders Can be
Prevented
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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)
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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
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School-based violence prevention can
reduce aggressive problems by onequarter to one-third
Social and emotional learning programs
may improve academic outcomes
Promising but limited benefit-cost
information
Citation
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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
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Parenting Programs (Incredible Years,
Triple P, Strengthening Families
Program)
Comprehensive Early Education
Family Disruption Interventions (e.g.,
Divorce, Maternal Depression)
School-Based Programs
Implementation
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Need to move from efficacy toward
effectiveness trials
Implementation research has
highlighted:
• complexity
• important role of community
Implementation Approaches
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Implement specific evidence-based
programs
Adapt (and evaluate) evidence-based
program to community needs
Develop and test community-driven
models
Screening
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Screening should meet modified WHO
criteria
Validated tool
Responsive to community priorities
Intervention available
Parent endorsement
Opportunities for Linkages with
Neuroscience
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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
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“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
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NIH should develop comprehensive 10year prevention and promotion research
plan
Research funders should establish parity
between research on preventive
interventions and treatment interventions
Mental Health America
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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
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Putting Knowledge into Practice
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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
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Make healthy mental, emotional, and
behavioral development a national priority
• Establish public prevention goals
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White House should establish ongoing multiagency strategic planning mechanism
• Align federal resources with strategy
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States and communities should develop
networked systems
Putting Knowledge Into Practice:
Funding
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Prevention set-aside in mental health
block grant
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Braided funding
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Fund state, county, and local prevention
and promotion networks
Putting Knowledge Into Practice:
Funding (Cont’d)
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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
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NIH should develop comprehensive 10year prevention and promotion research
plan
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Research funders should establish parity
between research on preventive
interventions and treatment interventions
Continuing a Course of Rigorous
Research: 10-Year Priorities
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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)
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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
“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.”
Depression in
Parents
Parenting
Practices
Development of
Children
Prevalence of Depression
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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
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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.
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Individuals should have informed choices in treatment
“tools” that are available to them
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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
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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
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Prevent or improve depression in the parent
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Target vulnerabilities of children of depressed parents
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Improve parent-child relationships
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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
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Rick Price and colleagues, University of
Michigan, Jobs Program – Jobs retraining for
unemployment
Irwin Sandler and colleagues, Bereavement
Program for those undergoing parental loss
Early Head Start
Each helps individuals and families accomplish ageappropriate developmental tasks and embeds
prevention and treatment in larger systems that
foster these.
Depression Prevention Examples
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Family Talk - Beardslee, et al., 2009
Prevention of depression - Garber, et al., 2009
Parent/Child Coping Session - Compas et al., in press.
Parental bereavement - Sandler
Home visitation – Putnam
The Incredible Years – Webster-Stratton
Early Head Start – parental depression
Mothers’ and babies’ program - Munoz
Seven Different Implementations of
Family Depression Approach
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Randomized trial pilot – Dorchester for single parent
families of color
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Development of a program for Latino families
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Large scale approaches – collaborations in Finland
and Norway
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Head Start – Program for parental adversity /
depression
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Blackfeet Nation – Head Start
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Costa Rica
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Collaboration with other investigators in new
preventive interventions; Project Focus
Commonalities Across Studies
With Efficacy Trial Data
1.
Strong theoretical orientation with an emphasis on
cognitive changes
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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
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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
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Report available at: http://www.nap.edu
Summary available as free download
Report briefs being developed
March 25 dissemination event
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Webcast of event to be posted on web
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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, 703713.
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.
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.