“Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth”: National Academies Report Calling for a Decade of Children and Youth

On September 11, 2019, the National Academies of Sciences, Engineering, and Medicine released its third consensus report in 25 years on the prevention of mental disorders and the promotion of mental, emotional, and behavioral health (1).

The first report, titled “Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research” (2) and released in 1994, concluded that we knew much about risk for mental disorders but that we did not yet have research evidence that preventive interventions could modify these risks and forestall the onset of mental disorders.

The 2009 report, titled “Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities” (3), concluded that, in the preceding 15 years, the field had produced substantial evidence that preventing the onset of certain specific mental disorders, particularly depression (4), was possible. Progress in research into the promotion of mental health justified expanding beyond treatment and prevention of mental disorders into interventions designed to promote healthy development. The report encouraged the fledgling research field of promotion of mental health to expand its work.

The 2019 report, “Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth,” began on a more somber note. While celebrating the remarkable research progress in understanding risk, epidemiology, neurobiology, prevention, and promotion in the mental health field, it noted much less progress in the implementation of these advances at the population level. Even though the mental health professions have developed many effective treatments for mental disorders, the prevalence of these disorders is not declining. The 2019 report points out that “rates of depression, suicide, and self-harm among young people have actually been increasing: in 2015, suicide was the second most common cause of death among young people aged 15 to 24, and between 2005 and 2014, the proportion of adolescents experiencing a major depressive episode increased from 8.7 percent to 11.3 percent” (1, p. 1).

The seriousness of the mandate to implement effective interventions to improve the mental health of children and youths is reflected in the report’s space allocation to the emerging field of implementation science. Numerous examples describe how to implement and scale up effective interventions, monitor fidelity, adopt programs, partner, and build capacity. The report challenges psychiatry to go beyond reduction of the prevalence of mental disorders via treatment and into reducing the incidence of such disorders via prevention and promotion interventions. The report calls for a national agenda (a “Decade of Children and Youth”) to bring together many elements in our communities (such as the health care system, the educational system, urban planners, the justice system, and national policy makers) to implement preventive and promotion interventions to reduce the incidence of mental, emotional, and behavioral disorders. The emphasis of this report is on improving the health and well-being of children and youths through action and implementation of the report’s recommendations.

The report addresses a broad group of players and will be of considerable interest to mental health researchers and policy makers working at the population level. However, there are gems of interest for the clinical researcher and the practicing clinician. The recommendation for intergenerational strategies for pregnancy, the postpartum period, and infancy will interest clinicians. There is a useful presentation of key prevention trials.

The 2019 report also reviews the growing understanding of how the individual’s environment throughout the life cycle (including parental experiences and behavioral practices before conception) interacts with epigenetic and neurobiological processes resulting in the development of mental disorders. It calls for the integration of neuroscience into population-wide preventive and promotion efforts. The review of the research that is relevant to such initiatives will be of value to investigators, who are encouraged to contribute to these initiatives to increase the likelihood that their work will have practical preventive implications.

Approaches to Prevention

Three approaches to the problem of how to prevent pathological development and promote healthy development were highlighted. These are:

1. A life-course approach taking into account the progression of illness across different life stages and recognizing that a chronic or treatment-resistant course of depression seen in older individuals may be the end stage of a disorder that was not prevented in youth and that, after onset, was untreated or poorly treated.

2. An intergenerational approach that acknowledges the contribution of maternal and paternal characteristics in the risk for mental disorders in offspring as well as the resources for well-being that these characteristics convey and uses this knowledge to provide treatment and preventive interventions at key life milestones, such as when couples are likely to conceive.

3. A population perspective on health that goes beyond a focus limited to individual functioning and takes into account family, community, and societal factors in human development that contribute to risk, calling into service the domains that may be helpful.

As one specific example from the many that could have been chosen, the report examines the evidence that perinatal depression in the mother has well-documented effects on the infant’s development and that these have long-lasting consequences to the brain and social development of the offspring across the lifespan.

The report concludes that we need to redouble our efforts to screen for clinical depression during pregnancy and the postpartum period and provide evidence-based treatment to the mother. In addition, we need to screen for the risk for perinatal depression and provide evidence-based preventive interventions (such as those recently recommended by the U.S. Preventive Services Task Force [5, 6]). Recent meta-analyses suggest that interventions focused on individuals at risk, that is, “indicated” preventive interventions, may be most efficient (6, 7) and thus the most practical way to introduce preventive interventions into routine health care. A new goal for the health care system should be to reduce the likelihood of onset of clinical depression in the mother who has mild symptoms or is at high risk because of a history of depression or other factors. Successfully preventing clinical depression perinatally may help avoid the difficult decision of whether to prescribe antidepressant medication during pregnancy. The combination of preventive and treatment interventions (for those whose depression is not prevented) can protect the infant from the sequelae of maternal depression and promote healthy development from the start of life. Early interventions during the life cycle could potentially have lifelong benefits. The report contains many other valuable recommendations that address preventive interventions for conditions beyond parental depression, such as anxiety disorders, substance misuse, and other mental, emotional, and behavioral conditions.

Recommendations

The report proposes several recommendations, many of which are at the policy level, including:

1. Relevant federal agencies should lead and collaborate with state and local agencies in coordinating a highly visible national effort to make the promotion of healthy mental, emotional, and behavioral development a national priority, such as by designating a Decade of Children and Youth.

2. Relevant federal agencies should use their program creation, regulatory, and other policy capabilities to promote healthy mental, emotional, and behavioral development and mitigate risks to mental, emotional, and behavioral health.

3. Relevant federal agencies should support rapid progress in the development and dissemination of effective mental, emotional, and behavioral prevention and promotion interventions for delivery to large populations by providing funding for these efforts.

4. The major health disciplines should add to their current training in diagnosis and treatment additional training in prevention and promotion research and practice.

5. The United States should establish an improved national system for the regular collection and coordination of data on indicators of mental, emotional, and behavioral development and health at the national, state, and local levels, as well as outcome data on efforts to promote health and prevent disorders.

Conclusions

Advances in the past 25 years, as documented in the three National Academies reports (1–3), challenge the field of mental health to look beyond treatment to the areas of prevention and promotion to reduce the incidence and the consequent prevalence of mental, emotional, and behavioral disorders. The call to focus beyond the individual and to examine family, community, and societal influences on mental health is not new to psychiatry. The social and community psychiatry movement has been addressing many of these issues since at least the 1960s. What is new is that science has advanced enough now to link together such outcomes as “infant birthweight, gestational age, and some childhood behaviors … to interactions between DNA sequence variation and aspects of prenatal environments, such as maternal smoking, depression, and body mass index” (1, p. 48).

What does this mean for psychiatry? First, increased attention and preventive intervention are needed early in symptom presentation before the course of a disorder crosses clinical threshold. Second, we need to recognize and pay attention to high-risk youths and high-risk situations; for example, the offspring of an acutely depressed parent may be at high risk. Third, stakeholders should join the interests of child and adult psychiatry, primary care, prenatal care, pediatrics, and behavioral neuroscience into actionable initiatives with the explicit goal of benefiting not only the individual but the health of the population as well.

Since this report was completed, the world has experienced a pandemic, which has affected the lives of everyone. The rates of depression, anxiety, and suicide, especially among the young, are reported to be rising. The recommendations of this report are even more relevant now.