Prevention Science Comes of Age

In special summer and fall issues of the American Journal of Community Psychology devoted to prevention science, researchers have described a new era in the science of preventing mental and behavioral disorders. In the lead article of the first issue, scientists from the Johns Hopkins School of Public Health and the National Institute of Mental Health (NIMH) describe how early warning signs have now been identified that carry increased risk of subsequent mental and behavioral disorders among vulnerable individuals. By designing scientifically sound preventive interventions to improve these early risk factors during childhood, the risk of developing disorders later on can be reduced.
Sheppard G. Kellam, MD, professor, Mental Hygiene, Johns Hopkins School of Public Health, and Drs. Doreen Koretz and Eve Moscicki from NIMH are guest co-editors of the two special issues and co-authors of the lead article. They state, "There are periods in scientific development that arouse intense excitement and a sense of optimism that things are on the right track. This is such a time in prevention research, with its experimental capacity to delve into developmental and causal processes."

The authors stressed that recent findings lend support for a general strategy of prevention science. Researchers first conduct epidemiological studies to identify early risk factors of later mental or behavioral disorders -- in the environment, or in the maladaptive responses by the child to important others such as teachers, parents, or peers. For example, prevention research has shown that aggressive and disruptive behavior, even as early as first grade, is an antecedent, or predictor, of cigarette smoking, other drug use, and delinquency among teenagers.

In a series of studies called the Baltimore Prevention Program, which began in 1984 and involved 19 elementary schools and 2311 children, Dr. Kellam and colleagues at the Johns Hopkins Prevention Research Center attempted to short-circuit this proven connection between aggression as early as first grade and later teen smoking and anti-social behavior. They introduced their intervention -- a classroom behavior management strategy designed to reduce aggressive behavior -- into certain first-grade classrooms but not into others, and then followed both groups of children into middle school. After following the children through elementary and into middle school, the researchers did indeed find that the teens who had participated in the behavior management intervention in first grade were significantly less likely to start smoking or engage in antisocial behavior during middle school compared to their counterparts who hadn't been in the prevention program.

The authors stressed that only if researchers carefully build partnerships among the population being studied and with leaders of the community or institutions involved, can well-designed randomized field trials such as the Baltimore Prevention Program be put in place. "Establishment and maintenance of trust and mutual self-interests lead to acceptance of rigorous scientific designs and procedures, and increase participation rates," said Dr. Kellam.

Before launching the 1984 Baltimore Prevention Program described above, the researchers paid careful attention to building trust and discovering mutual self-interests with leaders of the community. Because school administrators, teachers, and parents were full participants in the study's design and implementation, the 2,311 children were permitted to be randomly assigned to either intervention classrooms or standard classroom settings.

"The sophistication of that study's design," said Dr. Kellam, "was only possible because we first worked extensively to build trust and mutual self-interest among school leaders, parents, and teachers -- and in the children themselves as they matured. This process of base-building and the discovery of mutual self interests required about one year, and even today requires continuous maintenance, but the rewards can be amazingly satisfying scientifically, professionally, and personally."

The authors pointed out that policy makers at state and national levels are increasingly more likely to endorse and fund programs that have been rigorously tested by the methods of prevention science. If, when they compete for funds, local planners can cite scientifically based evidence, their bargaining position is considerably strengthened .

Dr. Kellam said, "The mission of all public health prevention programs is to forestall the onset of disease, or its recurrence. Health promotion and disorder prevention can ensure the growing competence of communities to socialize their young and to help all ages reach new levels of human potential."

The work was supported by the National Institute of Mental Health, with additional funding from the National Institute on Drug Abuse.