Prevention

As noted in the Surgeon General’s Report on mental health (1999), preventing an illness from occurring is inherently better than having to treat the illness after its onset. The term “prevention” has different meanings to different people. It also has different meanings to different fields of health. The classic definitions used in public health distinguish between primary prevention (prevention of a disease before it occurs), secondary prevention (prevention of recurrences or exacerbations of a disease that already has been diagnosed), and tertiary prevention (reduction in the amount of disability caused by a disease to achieve the highest level of function).  

The concepts of risk and protective factors, risk reduction, and enhancement of protective factors (also sometimes referred to as fostering resilience) are central to most empirically based prevention programs. Generally speaking, risk factors are those characteristics or variables that, if present for a given individual, make it more likely that this individual, rather than someone selected at random from the general population, will develop a disorder. Protective factors are those characteristics or variables that can improve a person’s response to a given stressor or condition, resulting in an adaptive outcome and positive impact on the influence exerted by risk factors. While related to the concept of protective factors, the construct of “resilience” is focused more on the ability of a single individual to withstand chronic stress or recover from traumatic life events.  

There is also an interface between prevention and promotion in the field of mental health; the distinction lies in their targeted outcomes. Mental health promotion aims to enhance positive mental health by increasing psychological well-being, competence and resilience, and by creating supporting living conditions and environments. Positive mental health serves as a powerful protective factor against mental illness. Mental disorder prevention has as its target the reduction of risk factors and the enhancement of protective factors associated with mental health problems, symptoms and disorders.

The definitions below are used by the Ohio Department of Mental Health and Addiction Servies (ODMHAS).

Alcohol and other drug specific

The term Alcohol and Other Drugs (AOD) includes, but is not limited to the following drugs of abuse - alcohol, tobacco, illicit drugs, inhalants, prescription and over-the-counter medications.

Alcohol and other drug prevention focuses on preventing the onset of AOD use, abuse and addiction. AOD prevention includes addressing problems associated with AOD use and abuse up to, but not including assessment and treatment for substance abuse and dependence. AOD prevention is a proactive multifaceted, multi-community sector process involving a continuum of culturally appropriate prevention services which empowers individuals, families and communities to meet the challenges of life events and transitions by creating and reinforcing conditions that impact physical, social, emotional, spiritual, and cognitive well-being and promote safe and healthy behaviors and lifestyles. AOD prevention is a comprehensive planned sequence of activities that, through the practice and application of evidence-based prevention principles, policies, practices, strategies and programs, is intended to inform, educate, develop skills, alter risk behaviors, affect environmental factors and/or provide referrals to other services.

Mental health specific

Mental health prevention service means actions oriented either toward reducing the incidence, prevalence, or severity of specific types of mental disabilities or emotional disturbances; or actions oriented toward population groups with multiple service needs and systems that have been identified through recognized needs assessment techniques. Prevention service may include but is not limited to the following: competency skills building, stress management, self-esteem building, mental health promotion, life-style management and ways in which community systems can meet the needs of their citizens more effectively.

Mental health consultation service means a formal and systematic information exchange between an agency and a person other than a client, which is directed towards the development and improvement of individualized service plans and/or techniques involved in the delivery of mental health services. Consultation service can also be delivered to a system (e.g., school or workplace) in order to ameliorate conditions that adversely affect mental health.Consultation services shall be provided according to priorities established to produce the greatest benefit in meeting the mental health needs of the community. Priority systems include schools, law enforcement agencies, jails, courts, human services, hospitals, emergency service providers, and other systems involved concurrently with persons served in the mental health system.Consultation may be focused on the clinical condition of a person served by another system or focused on the functioning and dynamics of another system.

Mental health education means formal educational presentations made to individuals or groups that are designed to increase community knowledge of and to change attitudes and behaviors associated with mental health problems, needs and services. Mental health education service shall:

• Focus on educating the community about the nature and composition of a community support program;
• Be designed to reduce stigma toward persons with severe mental disability or serious emotional disturbances, and may include the use of the media such as newspapers, television, or radio; and
• Focus on issues that affect the population served or populations identified as un-served or underserved by the agency.

Prevention Service Categories: Alcohol and other drug mental health

• Universal Prevention Services: Services target everyone regardless of level of risk before there is an indication of an AOD or mental health problem or mental illness;
• Selected Prevention Services: Services target persons or groups that can be identified as "at risk" for developing an AOD or mental health problem or mental illness; and
• Indicated Prevention Services: Services target individuals identified as experiencing a mental health problem or a problem behavior related to alcohol and other drug use to prevent the progression of the problem. These services do not include clinical assessment and/or treatment for substance abuse and dependence or for mental health problems or mental illness.

AOD Prevention Service Deliver Strategies

Information Dissemination is an AOD prevention strategy that focuses on building awareness and knowledge of the nature and extent of alcohol and other drug use, abuse and addiction and the effects on individuals, families and communities, as well as the dissemination of information about prevention, treatment and recovery support services, programs and resources. This strategy is characterized by one-way communication from source to audience, with limited contact between the two.

Alternatives are AOD prevention strategies that focus on providing opportunities for positive behavior support as a means of reducing risk taking behavior, and reinforcing protective factors. Alternative programs include a wide range of social, recreational, cultural and community service/volunteer activities that appeal to youth and adults.

Education is an AOD prevention strategy that focuses on the delivery of services to target audiences with the intent of affecting knowledge, attitude and/or behavior. Education involves two-way communication and is distinguished from information dissemination by the fact that interaction between educator/facilitator and participants is the basis of the activities. Activities affect critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities. The target audience does not include individuals already diagnosed with addiction.

Community-based process is an AOD prevention strategy that focuses on enhancing the ability of the community to provide prevention services through organizing, training, planning, interagency collaboration, coalition building and/or networking.

Environmentalprevention is an AOD prevention strategy that represents a broad range of activities geared toward modifying systems in order to mainstream prevention through policy and law. The environmental strategy establishes or changes written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of alcohol and other drug use/abuse in the general population.

Problem identification and refferal is an AOD prevention strategy that refers to intervention oriented prevention services that primarily targets indicated populations to address the earliest indications of an AOD problem. Services by this strategy focus on preventing the progression of the problem. This strategy does not include clinical assessment and/or treatment for substance abuse and dependence.

Sources:

Community Plan Guidelines for SFY 2010-2013 issued by the Ohio Department of Mental Health (ODMH) and the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) on September 29, 2010.

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.

Risk and protective factors can affect children at different stages of their lives. At each stage, risks occur that can be changed through intervening early in a child’s development to strengthen protective factors before problem behaviors develop. For instance, early childhood risks, such as aggressive behavior, can be changed or prevented with family, school, and community interventions that focus on helping children develop appropriate, positive behaviors. If not addressed, negative behaviors can lead to more risks, such as academic failure and social difficulties, which put children at further risk for later drug abuse.

The following table describes how risk and protective factors affect people in five domains, or settings, where interventions can take place.

Source: Preventing Drug Abuse among Children and Adolescents: Risk Factors and Protective Factors, National Institute on Drug Abuse (NIDA)

Risk and Protective Factors in Drug Abuse Prevention

As a result of 20 years of research, NIDA has identified the following “risk factors” that make drug use more likely:

• chaotic home environments, particularly in which parents abuse substances or suffer from mental illnesses
• ineffective parenting, especially with children with difficult temperaments or conduct disorders;
• lack of parent-child attachments and nurturing
• inappropriately shy or aggressive behavior in the classroom
• failure in school performance
• poor social coping skills
• affiliations with peers displaying deviant behaviors
• perceptions of approval of drug-using behaviors in family, work, school, peer, and community environments

And the following “protective factors” associated with reduced potential for drug use:

• strong and positive family bonds
• parental monitoring of children's activities and peers
• clear rules of conduct that are consistently enforced within the family
• involvement of parents in the lives of their children
• success in school performance; strong bonds with institutions, such as school and religious organizations
• adoption of conventional norms about drug use.

Risk factors can influence drug abuse in several ways. In general, the more risks a child is exposed to, the more likely the child will abuse drugs. Some risk factors may be more powerful than others at certain stages in development (such as peer pressure during the teenage years) just as some protective factors (such as a strong parent-child bond) can have a greater impact on reducing risks during the early years.

Likewise, some signs of risk can be seen as early as infancy or early childhood (such as aggressive behavior, lack of self-control, or difficult temperament). As the child gets older, interactions with family, at school, and within the community can affect that child’s risk for later drug abuse.

Major transitions in children's lives are high risk periods for drug abuse. 

Early Adolscence: When children transition from elementary school to middle school, they often experience new academic and social situations, such as learning to get along with a wider group of peers. Children are likely to encounter drugs for the first time at this stage as well.

Adolescence: When youth enter high school, they encounter additional social, emotional, and educational challenges. At the same time, they are likely exposed to greater availability of drugs, drug abusers, and social activities involving drugs. These challenges can increase the risk that they will abuse alcohol, tobacco, and other substances.

Young adults: When young adults leave home for college or work and are on their own for the first time, research has shown that their risk for drug and alcohol abuse is very high. 

Prevention Programs: Addressing Risk and Protective Factors

An important goal of prevention is to change the balance between risk and protective factors so that protective factors outweigh risk factors .Because risks appear at every life transition, it is important to strengthen protective factors at each stage of development and across family, school, and community settings.

Family - Prevention programs can strengthen protective factors among young children by teaching parents better family communication skills, appropriate discipline styles, firm and consistent rule enforcement, and other family management approaches. Family bonding is the bedrock of the relationship between parents and children and can be strengthened through parental communication and involvement such as talking to their children about drugs, monitoring their activities, getting to know their friends, understanding their problems and concerns, and being involved in their learning.
 
School - Prevention programs in schools are important since research shows that school failure is strongly associated with drug abuse. Programs that strengthen students’ bonding to school and reduce their likelihood of dropping out as well as those that focus on children’s social and academic skills (including enhancing peer relationships, self-control, coping, and drug-refusal skills) serve to strengthen protective factors against drug abuse. 

Community - Prevention programs work at the community level with civic, religious, law enforcement, and other government organizations to enhance anti-drug norms and pro-social behaviors. Leaders can assess community risk and protective factors associated with drug abuse to coordinate prevention efforts across settings to communicate consistent messages through school, work, religious institutions, and the media. They can also inform the development of policies or the enforcement of regulations.

Source:

Preventing Drug Use among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders. National Institute on Drug Abuse, Second Edition (October 2003).

The National Institute of Drug Abuse (NIDA) is part of the National Institutes of Health (NIH), a component of the U.S. Department of Health and Human Services. NIDA is charged with leading the Nation in bringing the power of science to bear on drug abuse and addiction through research across a broad range of disciplines and through ensuring the rapid and effective dissemination and use of the results of that research to significantly improve prevention, treatment and policy as it relates to drug abuse and addiction. Highlights from the booklet cited above are available via the In Brief Web edition which presents the updated prevention principles, an overview of program planning, and critical first steps for those learning about prevention. For information on “risk and protective factors”, click here.

Effective prevention programs can reduce risk factors, strengthen protective factors, and decrease psychiatric symptoms and disability and the onset of some mental disorders. They can also improve positive mental health, contribute to better physical health and generate social and economic benefits. The prevention of mental disorders targets those determinants that have a predisposing or causal influence on the onset of mental disorders.

There is strong evidence on risk and protective factors and their links to the development of mental disorders. “Risk factors”are associated with an increased probability of onset, greater severity and longer duration of major health problems. “Protective factors”refer to conditions that improve people’s resistance to risk factors and disorders; they modify, ameliorate or alter a person’s response to some environmental hazard resulting in an adaptive outcome. The cumulative effect of the presence of multiple risk factors, the lack of protective factors, and the interplay of risk and protective situations predisposes individuals to move from a mentally healthy condition to increased vulnerability, then to a mental problem and finally to a full-blown disorder. Risk factors are not static. They can change in relation to a developmental phase or to a new stressor in one’s life. Both risk and protective factors can be individual, family-related, social, economic and environmental in nature. Some risks such as gender and family history are fixed; others such as lack of social support, inability to read, and substance abuse can be altered or ameliorated. There is also interplay between biological and psychosocial risk factors as well between mental and physical health risk factors.

Prevention programs and interventions should be designed to counteract risk factors and reinforce protective factors along the lifespan in order to disrupt those processes that contribute to human mental dysfunction. They should encompass disease-specific as well as more generic risk and protective factors. “Disease-specific” risk and preventive factors are those that are mainly related to the development of a particular disorder, such as the relationship of major depression to suicide.

“Generic” risk and protective factors are those that are common to several mental health problems and disorders. Interventions that successfully address such generic factors may generate a broad spectrum of preventive effects. For example, risk factors that are common to many disorders include individual factors such as difficult temperament, chronic physical illness, and below-average intelligence; family factors such as severe marital discord, paternal criminality, maternal mental disorder, and admission into foster care; and community factors such as living in an area with a high rate of disorganization and inadequate schools.

Risk and protective factors in the Prevention on Mental Disorders

Individual and Family

Individual and family-related risk and protective factors can be biological, emotional, cognitive, behavioral, interpersonal or related to the family context. They may have their strongest impact on mental health at sensitive periods along the lifespan, and even have impact across generations. The more influence individual factors have on the development of mental disorders and mental health the greater the preventive effect that can be expected when they are addressed successfully. Individual protective factors are nearly identical to features of positive mental health such as self-esteem, emotional resilience, positive thinking, problem-solving and stress management skills, and feelings of mastery. For this reason, preventive interventions aiming to strengthen protective factors overlap largely with mental health promotion. Refer to the table below for some examples of individual and family risk and protective factors related to the onset of mental disorders.

Individual and Family Risk and Protective Factors Related to the Onset of Mental Disorders 

Social, Environmental and Economic

Major socioeconomic and environmental determinants for mental health are related to macro issues such as poverty, war and inequity. Changes in legislation, policy formulation and resource allocation can provide substantial improvements in the mental health of a population. In addition to improving mental health and reducing the risk for mental disorders, such legislative changes have also been proven to positively impact on the health, social and economic development of societies.

For example, according to the World Health Organization there is strong evidence that improving nutrition and development in socio-economically disadvantaged children can lead to healthy cognitive development, improved educational outcomes and reduced risk for mental disorders. Thus, macro-level prevention strategies focused on nutritional interventions not only reduce the risk for onset of mental disorders associated with poor nutrition but also provide protection in the form of improved cognition and education.

Implementation of effective regulatory interventions for addictive substances can include taxation, restrictions on availability and bans on advertising. By reducing the harm from use of addictive substances, these policy interventions can lead to the prevention of substance use disorders. Examples include laws that raise the minimum drinking age and the subsequent decrease in alcohol sales; and problem use among young drinkers and the enforcement of laws prohibiting the sale of tobacco to minors, thereby decreasing access and the use of tobacco by young people. The reduction in risk factors associated with substance abuse and access to drugs and alcohol occurs at both the individual/family and social/environmental/economic levels. Refer to the table below for some examples of social, environmental, and economic risk and protective factors related to the onset of mental disorders.

Social, Environmental, and Economic Risk and Protective Factors Related to the Onset of Mental Disorders

Sources:
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.

World Health Organization 
General information on the prevention of mental disorders and intervention strategies is available on the website. © Copyright World Health Organization (WHO), 2010. All Rights Reserved.

Information specific to risk and protective factors associated with the onset of mental disorders can also be found by accessing the report Prevention of mental disorders: effective interventions and policy options: Summary report/A report of the World Health Organization Dept. of Mental Health and Substance Abuse .Copyright World Health Organization 2004.

Additional resources:

PREVENTION OF SUBSTANCE ABUSE AND MENTAL ILLNESS: Create Prevention Prepared Communities where individuals, families, schools, faith-based organizations, workplaces, and communities take action to promote emotional health and reduce the likelihood of mental illness, substance abuse including tobacco, and suicide. This initiative will include a focus on the Nation’s youth, Tribal communities, and military families.

FINDYOUTHINFO.GOV is the U.S. government website that helps you create, maintain, and strengthen effective youth programs. Included are youth facts, funding information, and tools to help you assess community assets, generate maps of local and federal resources, search for evidence-based youth programs, and keep up-to-date on the latest, youth-related news.

BUILDING BLOCKS FOR A HEALTHY FUTUREis an early childhood substance abuse prevention program developed by the Substance Abuse and Mental Health Services Administration (SAMHSA) that educates parents and caregivers about the basics of prevention in order to promote a healthy lifestyle. Designed for parents and caregivers of children ages 3 to 6, Building Blocks will help you open up the lines of communication with young children—and make it easier to keep those lines of communication open as they grow older.

The materials and the Web site, which are designed for parents and caregivers to use with their children, are based on six action steps that relate directly to what researchers and substance abuse prevention professionals term family-related "protective factors." These are situations and conditions that decrease a child's chances for engaging in drug-related and other risky behaviors. The site also includes information about "risk factors" that increase children's risk for using alcohol, tobacco, and illegal drugs. With content focusing on children aged 3 to 6, the site includes topics such as how to better communicate with children, activities for promoting "family time," and what to say when discussing difficult issues.

SEARCH INSTITUTE® is an independent, nonprofit, nonsectarian organization whose mission is “to provide leadership, knowledge, and resources to promote healthy children, youth, and communities.” Search Institute helps people understand what kids need to succeed and to take action based on that knowledge through research and evaluation; the provision of tools and resources; and collaboration with partners. Search Institute serves all sectors of society, including K–12 and higher education, faith communities, youth-serving organizations, social-service organizations, families, businesses, and the public sector.

MONITORING THE FUTURE (MTF) is an ongoing study of the behaviors, attitudes, and values of American secondary school students, college students, and young adults. Each year, a total of approximately 50,000 8th, 10th and 12th grade students are surveyed. The Monitoring the Future Study has been funded under a series of investigator-initiated competing research grants from the National Institute on Drug Abuse, a part of the National Institutes of Health. MTF is conducted at the Survey Research Center in the Institute for Social Research at the University of Michigan.

NATIONAL SURVEY ON DRUG USE & HEALTH (NSDUH) provides the latest data on prevalence and correlates of substance use, serious psychological distress, depression, related problems, and treatment in the civilian population aged 12 or older in the U.S.

Note: formerly called the National Household Survey on Drug Abuse (NHSDA)

YOUTH RISK BEHAVIOR SURVEILLANCE SYSTEM (YBRSS) monitors priority health-risk behaviors and the prevalence of obesity and asthma among youth and young adults. The YRBSS includes a national school-based survey conducted by the Centers for Disease Control and Prevention (CDC) and state, territorial, tribal, and district surveys conducted by state, territorial, and local education and health agencies and tribal governments.