VI. Summary of Findings
review offers evidence that important and meaningful progress
has been made in prevention research with children, families and
schools during the last two decades. There have been advances
in the theory, design, and evaluation of programs, and there are
a growing number of programs with documented efficacy of beneficial
impact on the reduction on psychiatric symptomology. These research
findings have also influenced public policy as federal, state,
and local governments are now calling for the utilization of empirically-validated,
effective models of intervention for children and families.
Best Practices in Prevention Programming
Over time, researchers, practitioners, and policy makers have
developed a more realistic perspective on the necessary intensity
and comprehensiveness of programming to prevent psychopathology
and promote positive development, especially with children and
adolescents growing up in high-risk environments (Panel on High-Risk
Youth, National Research Council, 1993). The following conclusions
can be made regarding validated programs:
- Short-term preventive interventions produce time-limited
benefits, at best, with at-risk groups whereas multi-year programs
are more likely to foster enduring benefits.
- Although preventive interventions may effectively operate
throughout childhood (when developmentally-appropriate risk and
protective factors are targeted) given the resistance to treatment
of serious conduct problems, ongoing intervention starting in
the preschool and early elementary years may be necessary to
- Preventive interventions are best directed at risk and protective
factors rather than at categorical problem behaviors. With this
perspective, it is both feasible and cost-effective to target
multiple negative outcomes in the context of a coordinated set
- Interventions should be aimed at multiple domains, changing
institutions and environments as well as individuals.
- Prevention programs that focus independently on the child
are not as effective as those that simultaneously "educate"
the child and instill positive changes across both the school
and home environments. The success of such programs is enhanced
by focusing not only on the child's behavior, but also the teacher's
and family's behavior, the relationship between the home and
school, and the needs of schools and neighborhoods to support
healthy norms and competent behavior.
- There is no single program component that can prevent multiple
high-risk behaviors. A package of coordinated, collaborative
strategies and programs is required in each community. For school-aged
children, the school ecology should be a central focus of intervention.
- In order to link to other community care systems and create
sustainability for prevention, prevention programs will need
to be integrated with systems of treatment. In this way, communities
can develop common conceptual models, common language, and procedures
that maximize the effectiveness of programs at each level of
need. Schools, in coordination with community providers, are
a potential setting for the creation of such fully-integrated
models. It is surprising that few comprehensive interventions
have been developed and evaluated that combine school-wide primary
prevention together with secondary prevention and treatment.
The past decade has brought to fruition well-designed studies
that demonstrate the potential of preventive intervention in reducing
harmful symptoms for children and youth. However, given the need
for effective research in this field there are numerous issues
for future research, policy, and practice.
- Few studies meet the criteria for fully-validated program
models. Of most concern are the lack of replication of program
effects by independent investigators and the absence of long-term
follow-up to examine stability of program effects.
- One of the weaknesses in present research efforts is the
lack of comprehensive follow-up data to chart the developmental
processes of program participants in the years after receiving
interventions. As a number of programs show stronger impacts
at follow-up than they did at post-test, it is likely that the
effects of prevention programs are underestimated at present;
examining distal outcomes is critical.
- There has been greater attention to preventive interventions
focused on externalizing disorders. As such, we still know less
regarding effective prevention models for internalizing disorders.
Further, as many children show risk for, or co-morbidity of
internalizing and externalizing problems, intervention projects
should examine the differential effects that interventions might
have on those that have risks or early symptoms of co-morbidity.
Further, outcome measures should include assessment of both
externalizing and internalizing symptoms.
- A broader point is that there is significant inter-individual
variability in program effects. There has been little focus on
what factors in the child (e.g., gender, ethnicity) or environment
(e.g., quality of home or school environment) might moderate
the impact of intervention. It is necessary to know more regarding
for whom specific programs are most likely to be effective.
- With few exceptions, there has been little exploration of
how the quality of implementation affects outcomes. There is
a need for greater attention to both the measurement of dosage
as well as the quality and fidelity of the intervention delivery,
especially as empirically-validated prevention programs begin
to "go to scale."
- Due in part to the categorical nature of funding, programs
often assess quite narrow outcomes (e.g., only substance abuse,
psychological symptoms, positive adaptation). As programs often
focus the intervention on modifying common risk factors for multiple
problem behaviors as well as promoting competence, measures of
multiple dimensions of outcome are necessary.
In spite of substantial gains in prevention research during
the last two decades, it is important to acknowledge that considerable
progress is needed to affect more tangibly the lives of American
children and families. Only a small group of researchers have
designed and evaluated multi-year, multi-component programs that
target multiple mental health outcomes. Few successful efficacy
trials have been replicated by independent investigators, and
there have been even fewer attempts to evaluate the implementation
process and impact of widely disseminated program models. In summary,
although a solid scientific base is being created, the most important
knowledge regarding preventive interventions will come from the
next generation of prevention researchers!