The effectiveness of universal mental health prevention has been well established, with a demonstrated return on investment seen for a number of models.1 The importance of prevention is highlighted by some concerning statistics. In the United States, 22% of teenagers have experienced a mental illness, and half of all lifetime mental illness starts by age 14. Yet only 50% of youth with a mental health disorder receive treatment.2 Thus, universal prevention strategies have significant potential for reducing the burden of pediatric mental illness on children and adolescents, their families, and society.
In “Adolescent Mental Health Program Components and Behavior Risk Reduction: A Meta-analysis,” Skeen et al3 note that past reviews of prevention models have focused on single-issue interventions and outcomes. By contrast, their meta-analysis of universal prevention models for adolescents sought to identify common practice components in proven interventions across multiple outcomes. This was done with the express intent of developing a universal model to affect multiple outcomes as part of the Helping Adolescents Thrive initiative sponsored by the World Health Organization and United Nations Children’s Fund. This is potentially more cost-effective than using multiple single-focus models and therefore more feasible for use in low- and middle-income countries. Such an approach holds promise because there is evidence that universal programs can influence multiple outcomes in a younger population. The PAX Good Behavior Game, a universal prevention model teaching children self-regulation skills in schools, for example, has demonstrated a positive impact on academic and behavioral outcomes in schools and positive effects on aggression, substance abuse, and suicidality into adulthood.4,5 As noted by the authors, a potential barrier to the effectiveness of a new model for low- and middle-income countries is that the majority of randomized controlled trials included in this study are from high-income countries.
Of the 25 practice components investigated by Skeen et al,3 only 3 consistently predicted positive effects across >1 outcome: interpersonal skills, emotional regulation, and alcohol and drug education. Interpersonal skills and emotional regulation are critical for a healthy developmental trajectory,6 so this finding comes as no surprise. Although early childhood is the optimal developmental phase to begin acquiring these skills, adolescence still clearly provides an opportunity for prevention. Interestingly, alcohol and drug education had positive effects on outcomes not related to alcohol and drugs, namely positive mental health and aggression, but not on substance use. As Skeen et al3 propose, the effects of alcohol and drug education on positive mental health and aggression may be due to shared risk and protective factors as well as shared prevention pathways. Four additional practice components predicted positive effects in 1 outcome category only.
Skeen et al3 also identify practice components that were ineffective or possibly harmful. Surprisingly, some components commonly considered effective in the treatment arena were found not to be predictive in either direction. These include cognitive restructuring, behavioral activation, and social skills.
The authors examined mode of delivery, comparing face-to-face interventions with digital or combined interventions. Across all time points, face-to-face interventions showed benefits for positive mental health, depression and anxiety, and aggression. Digital or combined modality interventions showed benefits for positive mental health and substance abuse across all time points and a short-term effect for depression and anxiety. The digital environment and social media have seen rapid change and growth over the past few years. Although social media have been linked to negative impacts on mood,7 it also holds tremendous potential for prevention with adolescents, particularly those who are hard to engage.8
It is notable that of the 158 randomized controlled trials identified by the authors, only 2 reported on suicide and self-harm outcomes. This is concerning because suicide is now the second leading cause of death for adolescents in the United States, and the rate has been steadily increasing over the past decade. In 2017, 2954 youth ages 12 to 19 died by suicide, yet funding for suicide-prevention research lags significantly behind other causes of death for this age group.9 There is an urgent need for more research into the causes and prevention of suicide if we are to reverse this unsettling trend.
Despite demonstrated effectiveness, funding for implementing prevention is challenging. Transportability and implementation of evidence-based models in real-world contexts often depend on resources such as funding, and sustainability can pose a barrier.10 Furthermore, the sheer number of available models can be confusing for entities such as schools, and models are often adopted in the absence of a comprehensive strategy or without careful consideration of contextual nuances. These issues can complicate program adoption, and furthermore, effective implementation and sustainability may require resources that are unavailable in low-income communities. This maintains disparity in access to mental health resources, with the unintended consequence being that economically marginalized families are even less likely to be exposed to high-quality interventions. If we are to close the gap in social determinants of health, a concerted effort to fund and implement prevention and evaluate effectiveness and transportability is imperative.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-3488.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.