Risk Factors are not predictive factors due to protective factors Carl C. Bell, MD Prospects for the Prevention of Mental Illness: New Developments and

Risk Factors are not predictive factors due to protective

factorsCarl C. Bell, MD

Prospects for the Prevention of Mental Illness:New Developments and New Challenges

Committee Charge

Review promising areas of research Highlight areas of key advances and

persistent challenges Examine the research base within a

developmental framework Review the current scope of federal efforts Recommend areas of emphasis for future

federal policies and programs of research

Committee Members

KENNETH WARNER (Chair), School of Public Health, University of Michigan THOMAS BOAT (Vice Chair), Cincinnati Children’s Hospital Medical Center WILLIAM R. BEARDSLEE, Department of Psychiatry, Children’s Hospital Boston CARL C. BELL, University of Illinois at Chicago, Community Mental Health Council ANTHONY BIGLAN, Center on Early Adolescence, Oregon Research Institute C. HENDRICKS BROWN, College of Public Health, University of South Florida E. JANE COSTELLO, Department of Psychiatry and Behavioral Sciences, Duke

University Medical Center TERESA D. LaFROMBOISE, School of Education, Stanford University RICARDO F. MUNOZ, Department of Psychiatry, University of California, San Francisco PETER J. PECORA, Casey Family Programs and School of Social Work, University of

Washington BRADLEY S. PETERSON, Pediatric Neuropsychiatry, Columbia University LINDA A. RANDOLPH, Developing Families Center, Washington, DC IRWIN SANDLER, Prevention Research Center, Arizona State University

MARY ELLEN O’CONNELL, Study Director

IOM: Reducing Suicide Report where the notion that risk factors were not predictive factors due to protective factors developed.

Categories of Adverse Childhood Experiences

Psychological abusePhysical abuseSexual abuseViolence against motherLiving with household members who were

substance abusersLiving with household members who were

mentally ill or suicidalLiving with ex-offender household members.

RESULTS

More than half of respondents (52%) experienced > 1 category of adverse childhood exposure

6.2% reported > 4 exposures.

RESULTS

Persons who experienced 4 or more categories of childhood exposure, compared to those who had experienced none had:7.4 fold increase for alcoholism10.3 fold increase for drug abuse4.6 fold increase for depression12.0 fold increase in suicide attempts.

RESULTS

Persons who experienced 4 or more categories of childhood exposure, compared to those who had experienced none had 2.2 fold increase in smoking2.2 fold increase poor self-rated health 3.2 fold increase in > 50 sexual

intercourse partners2.5 fold increase in sexually

transmitted disease.

RESULTS

Persons who experienced 4 or more categories of childhood exposure compared to those who had experienced none had2.2 fold increase in ischemic heart disease1.9 fold increase cancer,3.9 fold increase in chronic lung disease

(bronchitis and emphysema),1.6 fold increase in skeletal fractures,2.4 fold increase in liver disease.

Facts about Depression & Suicide

20,000 out of 100,000 people get depressed 5,000 out of 100,000 people attempt suicide 11-20 out of 100,000 people complete

suicide. Something must be protecting the 19,980

people who are depressed and the 4,980 people who have attempted suicide.

Trauma is Ubiquitous

Bell & Jenkins (1985) found that 25% & 30% of inner-city Chicago youth, ages 7-15, had seen a shooting & stabbing.

Using structured telephone interviews in a national sample of 4,008 adult women, Resnick et al (1993) found a lifetime rate of exposure to any type of traumatic event of 69%.

Kessler et al (The National Comorbidity Survey - 1995) found that more 50% of nearly 6,000 subjects, ages 15 – 54, had experienced a traumatic event during their lifetime & most people had experienced more than one.

Breslau et al (1998) examined trauma exposure & the diagnosis of PTSD in a community sample of 2,181 individuals in the Detroit area and found that the lifetime prevalence of trauma exposure was 89.6%.

Exposure To A Traumatic Event Does Not Automatically Put A person On A Path To Develop PTSD: The Importance

of Protective Factors To Promote Resiliency

Kessler et al (1995) found 8% of males and 20% of females Breslau et al (1992) found 10% of males and 14% of females

who were exposed to trauma had a lifetime prevalence rate of PSTD)

Exposure to a traumatic stress does automatically mean a victim of trauma is predisposed to develop PTSD.

Most people affected by a trauma event will adapt in a period of 3 – 6 months following trauma (Riggs et al, 1995) and only a small proportion will develop long-term psychiatric disorders (Bryant, 2006; Bryant 2006).

Paradigm Shift

“Risk factors are not predictive factors because of protective

factors.”

Child Welfare: CANS Psychiatric Symptoms Integrated Assessment, FY06

25.4

17.9 17.7 16.7

0

5

10

15

20

25

30

Trauma Attach Anger Depress

% N=1375

The Impact of Trauma Experiences on Risk Behaviors

-2

-1.5

-1

-0.5

0

0.5

1

1.5

2

-2 -1.5 -1 -0.5 0 0.5 1 1.5 2

Traumatic Experience Score (10,25,50,75,90 Pctl)

Ris

k A

ve

rag

e (

z)

-2

-1.5

-1

-0.5

0

0.5

1

1.5

2

-2 -1.5 -1 -0.5 0 0.5 1 1.5 2

Traumatic Experience Score (10,25,50,75,90 Pctl)

Ris

k A

ve

rag

e (

z)

STR 90th Pctl = 1.27

STR 75th Pctl = 0.72

STR 50th Pctl = -0.01



Risk of Symptoms & Strengths

The Contribution of Prevention Science

The scientific foundation has been created for the nation to begin to create a society in which young people arrive at adulthood with the skills, interests, assets, and health habits needed to live healthy, happy, and productive lives in caring relationships with others.

Disorders Are Common and Costly

Around 1 in 5 young people (14-20%) have a current disorder

Estimated $247 billion in annual costs Costs to multiple sectors – education,

justice, health care, social welfare Non-monetary costs to the individual

and family

Dr. David Satcher’s Children’s Mental Health Conference suggested our Nation focus on:• Children in Child Protective Services•Children in Juvenile Justice Facilities•Children in Special Education

Preventive Opportunities Early in Life

Early onset (¾ of adult disorders had onset by age 24; ½ by age 14)

First symptoms occur 2-4 years prior to diagnosable disorder

There are common risk factors for multiple, different problems and disorders

NIMH Prevention Spending - 2008 Prevention (RCDC FY2008) = $208,278,505

695 grants in this pile but only 60 (8.6%) were prevention grants. Prevention Effectiveness Research (RCDC FY2008) = $34,281,125

107 grants in this category and about 32 (29.9%) were prevention grants. Prevention Health Services Research (RCDC FY2008) = $28,970,981

100 grants here but only 15 (15%) were prevention grants (liberaldefinition).

Dissemination and Implementation Research = $23,746,06267 of these grants and 6 (9%) were prevention grants.

Dissemination and Implementation Research in Prevention = $4,703,19518 grants and 6 (33%) were prevention grants & some PI's were in the above category.

Effectiveness Research (RCDC FY2008) = $76,805,163217 grants and 32 (14.5%) were prevention grants.

Health Services Research (RCDC FY2008) = $94,273,008328 grants and 16 (4.9%) were prevention grants & some PI’s were in theabove category.

Research Funding Illustration

Key Core Concepts of Prevention

1. Prevention requires a paradigm shift

2. Mental health and physical health are inseparable

3. Successful prevention is inherently interdisciplinary

4. Mental, emotional, and behavioral disorders are developmental

5. Coordinated community level systems are needed to support young people

6. Developmental perspective is key

24

Explosion in Randomized Trials

How are we functioning?

Different languageDifferent language Different goals Different goals

Resource silosResource silosActivity-drivenActivity-driven

We need Synergy and a Integrated System

Common languageCommon language

Evidence basedEvidence based

Maximize resourcesMaximize resources

Outcome driven

Outcome driven

Common Risk Factors for Multiple Problems Poverty

Coercive processes in families

Lack of self-regulation

Aggressive social behavior that is developmentally appropriate

Risk Factors Are Not Predictive Factors Due To Protective Factors

The Critical Role of Self-Regulation Neuroscience and behavioral

research are converging on the importance of self-regulation for successful development

Children who do not develop the capacity to inhibit impulsive behavior, to plan, and to regulate their emotion are at high risk for behavioral and emotional difficulties

Prevention Window

Defining Prevention and Promotion

Prevention should not include the preventive aspects of treatment

Prevention and promotion overlap, but promotion has important distinct role

Mental health not just the absence of disorder

Mental Health Promotion Aims to: Enhance individuals’ ability to achieve

developmentally appropriate tasks (developmental competence)

Enhance individuals’ positive sense of self-esteem, mastery, well-being, and social inclusion

Strengthen their ability to cope with adversity

Prevention AND Promotion

Preventive Intervention Opportunities

Generic Features of Preventive Interventions

Reduce or minimize toxic biological and psychological processes

Richly reinforce self-regulated, prosocial behavior

Teach prosocial skills and values Foster acceptance

Evidence that Some Disorders Can be Prevented

Risk and protective factors focus of research

Interventions are tied to these factors Multi-year effects on substance

abuse, conduct disorder, antisocial behavior, aggression and child maltreatment

Evidence that Some Disorders Can be Prevented

Indications that incidence of adolescent depression can be reduced

Interventions that target family adversity reduce depression risk and increase effective parenting

Emerging evidence for prevention of clinical schizophrenia

Nurse-Family Partnership* Pregnancy through infancy Focus on

Prenatal care Maternal smoking Mothering Contraception Work life

* Funded in part by NIDA

Nurse-Family Partnership Evaluated in three randomized trials for

poor, teenager single mothers, Significant effects on

Abuse and neglect

Children’s behavioral development

Mother’s economic wellbeing

Time to next baby

Children’s arrest as adolescent

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

Comparison Nurse P Nurse P&I

PC-NP & C-NPI = .005

Adjusted rates of arrests, 15-year olds, Elmira

CPS CRADLE TO CLASSROOM

Collaborative initiative with Chicago Public Health Department, six hospitals, & other agencies for pregnant & parenting teens

Trains teens in the development of parenting skills and accessing community resources

Provides teens access to prenatal, nutritional, medical, social, and child care services

Provides counseling to new mothers around issues of domestic violence

CPS CRADLE TO CLASSROOM

Some 2000 teenagers in 54 Chicago schools that offer this program had babies in 2002. All 495 seniors graduated, and 78% of them enrolled in 2- or 4-year college programs.

Only 5 of the women had a repeat pregnancy while still in school; 4 were graduating seniors, and the other, a junior, stayed in school. Eighty-five teen fathers also participated in the program, learning parenting skills under the supervision of a male mentor at each school.

The program's annual budget was $3.7 million

Positive Parenting Program—Triple P*

A community-wide system of parenting supports that includes brief media communications,

brief advice for specific problems, and

more extensive interventions when needed

Multiple randomized trials showing benefit Including an RCT in 18 counties in South

Carolina


Substantiated Child Maltreatment

0

4

8

12

16

Ra

tes p

er

1,0

00

Ch

ild

ren

(0

-8 Y

ea

rs)

Triple P Counties Control Counties

Before Triple P After Triple P

.000

.500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

4.500

Ra

tes

pe

r 1

,00

0 C

hild

ren

(0

-8 Y

ea

rs)

Triple P Counties Control Counties

Child Out-of-Home Placements

Effect size = 1.22, p <.01, showing Triple P decreased medical injuries in counties using Triple P, compared to control counties not receiving Triple P increasing.

Before Triple P After Triple P

Strengthening Families 10-14 (Spoth et al., 2001)*

Group-based parenting program for parents of early adolescents

Effects up to six years later

Reduced tobacco, alcohol, & drug use—including methamphetamine use

Reduced delinquency Cost-effectiveness (Aos et al., 2004)

Savings of $7.82 per dollar invested

Total savings of $5,805 per youth

* Funded by NIDA

The Family Check-Up* Provides parenting support to families of adolescents via

a family resource center in middle schools Effects as much as five years later

Reduced substance use

Fewer arrests

Better school attendance & academic performance Cost-effectiveness (Aos et al., 2004)

Savings of $5.02 per dollar invested

Total savings of $1,938 per youth


New Beginnings Program (NBP)

Small group program for divorcing families

Emphases on learning new skills and applying them in the family

56

79

16

8

28

13

0

10

20

30

40

50

60

70

80

Per

cent

age

0 - 2 3 - 9 10 +

Number of Use

Marijuana Use -- Last 12 Months

Control NBP

CMHC’s Work in McLean County, Illinois The twin cities of Bloomington/Normal and

Peoria, Illinois are located in McLean and Peoria counties, respectively, 135 -160 miles South of Chicago.

The two cities have a combined population base of 227,000 residents (Brinkhoff, 2005), approximately 25 percent of whom are African-American (Children and Family Research Center, 2003).

CMHC’s Work in McLean County, Illinois Of the counties in this Central Illinois area

(Fulton, Marshall, McLean, Peoria, Tazwell, and Wollford), McLean and Peoria are the only two with a substantial African-American population – 10.2% and 37.6% respectively, with all the rest having less than 1% (Children and Family Research Center, 2003).

CMHC’s Work in McLean County, Illinois In 1999, the Illinois Department of Children and Family

Services learned there was a problem in child protective services in McLean & Peoria counties in Illinois

In 1999, the average rate of removal of children from their families was 4/1,000.

In 1999, in McLean and Peoria counties in Illinois, the average rate of removal of children from their families was 35 - 40/1,000.

By 2000, in McLean and Peoria counties in Illinois, the official rate of removal of children from their families was 25/1,000.

CMHC’s Work in McLean County, Illinois In early 2001, CMHC’s Executive

Administrative Team began a comprehensive assessment of the child protective services in McLean and Peoria counties.

CMHC’s Work in McLean County, Illinois The assessment included windshield surveys

(the process of driving through the community and noting community strengths, e.g. a youth recreational club, and deficits, e.g., a crack house) across the city and interviews with DCFS consumers, key informants from the State’s Attorney’s Office, DCFS employees, elected officials, community activitists, case workers, and other social service agency workers.

CMHC’s Work in McLean County, Illinois Completed in late 2001, the assessment

revealed IDCFS was quite active in taking custody of children felt to be in danger in McLean and Peoria County.

There were three private (purchase of service – POS) agencies in McLean County that received children taken into custody.

Investigations were neither comprehensive nor complete, and African-Americans had become extremely distrustful of IDCFS procedures.

CMHC’s Work in McLean County, Illinois Parents and alleged perpetrators reported they

were not being informed of their rights or the results of the investigation consistently.

Additionally, when children were taken into state custody, children and their parents were not being prepared for placement.

The McLean and Peoria offices were making placement decisions before collecting all required information, and without considering all possible alternatives to placement.

CMHC’s Work in McLean County, Illinois

When investigations raised concerns about domestic violence, African-American children were quickly taken into custody despite the dearth of domestic violence treatment services needed to rehabilitate the family.

The same occurred in cases involving alcohol & substance abuse, there were few treatment services available to address the issue


In addition, inconsistent application of policies governing investigations and case management further compounded the problem. Lastly, the assessment found that the documentation in investigative and service case files did not always provide evidence that investigators and caseworkers were receiving regular supervision. Further, services to intact families needed substantial improvement.


Both the McLean County & the Peoria County field offices experienced a significant amount of turnover of child welfare service workers & supervisors. Moreover, since there was only one field supervisor and one clinical services manager for both offices, the constant demand to train new staff negatively impacted the way cases were handled at both sites.

Triadic Theory of Influence

Sociological theories of social control and social bonding (Akers et al., 1979; Elliott et al., 1985)

Peer clustering (Oetting & Beauvais, 1986) Cultural identity (Oetting & Beauvais, 1990-91) Psychological theories of attitude change & behavioral

prediction (Fishbein & Ajzen, 1975; Ajzen, 1985) Personality development (Digman, 1990) Social learning (Akers et al., 1979; Bandura, 1977, 1986) Integrative theories (e.g., Jessor & Jessor's, Problem Behavior

Theory; Brook’s Family Interaction Theory, Hawkins’ Social Development Theory)

See Petraitis, Flay and Miller (1995).

Intra-personalStream

Social/Normative

Stream

Cultural/Attitudinal

Stream

Community PsychiatryHealth Behavior Change

Field Principle Operationalization

Rebuilding the village Build community collaborations to support troubled families

Providing access to modern technology Transport evidence-based assessment and treatment to the community

Increasing connectedness Organizational/staff development

Increasing social and emotional skills Organizational/staff development

Increasing self-esteem Actualize quality assurance systems to monitor IDCFS practices

Reestablishing the adult protective shield Actualize quality assurance systems to monitor IDCFS practices

Minimizing trauma Take a system approach to the problem & ensure that each stakeholder has support

Strategies and InterventionsUrban Services

Family AdvocatesThe purpose of the Family Advocate is to provide advocacy

and case management services to children and their families who are involved in the child welfare system.

The Family Advocate ensures the delivery of culturally competent services through on-going support and guidance to children and their families.

The program was implemented in August 2002 in which the Advocates completed departmental trainings (Foundation, Child Protection Investigations, and Child Welfare Specialists) along with becoming CERAP certified. Partnerships with Faith Based Community.

Strategies and InterventionsDCFS

Citizen Quality Assurance Panel While waiting for this panel to be operationalized, CMHC

has been performing this task. The Citizen Quality Assurance Panel - voluntary Citizen

Review Panel established using the National Association of Roster Reviewers’ guidelines for independent reviews.

Review cases regarding safety decisions that were made during the investigative process or when families request a special review of their opened intact or permanency cases based on services identification and delivery, the lack of reasonable efforts made by the IDCFS/POS agency, and other identified permanency issues.

Outcomes in McLean County FY00 through FY02

Reported Abuse and Neglect by Race

31.125.1

149

43.337.4

0102030405060708090

100110120130140150

FY00 FY02

European-American (- 19.3%)

African-American (- 1.5%)

Hispanic (- 13.6%)

Outcomes in McLean County FY00 through FY02

Children Removed by Race

3.691.58

35.05

13.58

1.16 1.16

0

5

10

15

20

25

30

35

40

FY00 FY02

European-American (- 57.2%)

African-American (- 61.3%)

Hispanic (0%)

Evidence that Depressive Disorders Can be Prevented Clarke et al. (2001) found that a

group program for adolescent offspring of depressed parents could reduce the incidence of depression to a level no higher than for adolescents whose parents were not depressed.

Bruce, Fisher, Pears, & Levine (2008)

Relation between Neglect and Morning CortisolLevels

0

0.5

1

1.5

2

2.5

3

Morning Cortisol Level

Severi

ty o

f N

eg

lect

Low Average High

F(2, 114) = 4.27, p < .05

Severity neglect in low, average, and high morning cortisol groups

0

0.5

1

1.5

2

2.5

3

Morning Cortisol Level

Severi

ty o

f N

eg

lect

Low Average High

F(2, 114) = 4.27, p < .05

Foster kids and adoptees from overseas orphanages show this disrupted pattern involving low daytime cortisol, and associated with neglect

Multidimensional Treatment Foster Care for Preschoolers (MTFC)

Training of foster parents in behavioral parenting practices

24/7 support of foster parents RCT comparing MTFC with Regular

Foster Care (RFC) Reduction in caregiver stress Increase blunted diurnal HPA axis

activity for RFC and return to stable Diurnal activity for MTFC children

The Good Behavior Game* Classrooms are divided into teams, and

each team can win rewards if the entire team is “on task” (e.g., fewer than a specified number of rule violations during the game period) or otherwise acting in accordance with previously stated teacher expectations

Rewards include extra free time, stars on charts, and special team privileges.


The Good Behavior Game* Classroom teams in elementary school earn small

rewards for being on-task and cooperative Randomized trial in Baltimore Inner City Schools

Had preventive effects even

into young adulthood

Substance abuse disorders

Antisocial personality


A Good Behavior Game Result

Aban Aya* Chicago high poverty African-American

neighborhoods School/community intervention

Social skills training In-service training of school staff; Task force to develop policies, conduct school-wide fairs,

seek funds for the school, & conduct field tripsParent training workshops.

Significant effects on violence, drug use, & boys recent sexual intercourse


Community Psychiatry Protective Factor Field Principles

Rebuilding the Village/Constructing Social Fabric Access to Modern Medical Technology Connectedness Social Skills Self Esteem - Activities that create a sense of power; a

sense of connectedness; a sense of models; a sense of uniqueness

Reestablish the Adult Protective Shield Minimize the Effects of Trauma

RE-ESTABLISHING THE ADULT PROTECTIVE SHIELD OUTCOMESCPS SUMMARY

1997-1998 1998-1999 1999-2000# Random sweeps

59 65 89

Firearms 0 1 1Knives, box cutters, razors

107 96 54

Narcotics 75 63 51Other weapons

158 200 29

Evidence of School-related Effects

School-based violence prevention can reduce aggressive problems by one-quarter to one-third

Social and emotional learning programs may improve academic outcomes

Promising but limited benefit-cost information

Needed to Build on Existing Knowledge Effectiveness trials Dissemination Research

Experimental evaluations of dissemination strategies

Implement evidence-based programs, policies, and “kernels”

Comprehensive neighborhood and community interventions

Prevention is possible

Teacher training in classroom instruction & management, child social & emotional skill development, & parent workshops were the intervention.

A significant multi-varied effect across all 16 primary outcome indices were found.

Specific effects included significantly better educational and economic attainment, mental health and sexual health by age 27 years (all P<.05).

Hawkins JD, Kosterman R, Catalano RF, Hill KG, and Abbott RD. Effects of Social Development Intervention in Childhood 15 Years Later. Arch Pediatr Adolesc Med. 162(12), pp 1133-1141, 2008.

Implementation

Need to move from efficacy toward effectiveness trials

Implementation research has highlighted:ComplexityConsideration of the important role

of community

Implementation Approaches

Implement specific evidence-based programs

Adapt (and evaluate) evidence-based program to community needs

Develop and test community-driven models

Opportunities for Linkages with Neuroscience

Interactions between modifiable environmental factors and expression of genes linked to behavior

Greater understanding of biological processes of brain development

Opportunities for integration of genetics and neuroscience research with prevention research

Recommendation Themes

Putting Knowledge into Practice Continuing Course of Rigorous

Research

Putting Knowledge Into Practice: Overarching Recommendations

White House should establish ongoing multi-agency strategic planning mechanism& Align federal resources with the strategyPatient Protection and Affordable Care Act.

States and communities should develop networked systems


Make healthy mental, emotional, & behavioral development a national priority by establishing public prevention goals. The first, the National Prevention, Health

Promotion, & Public Health Council, will sit at the Department of Health and Human Services, and will be chaired by the Surgeon General.

The Council will provide federal coordination & leadership in regard to prevention, wellness, health promotion, the public health system, & integrative health care, & will develop a National Prevention Strategy.


State grants for evidence-based early childhood home visitation programming are also included in health reform. $1.5 billion over five years will be awarded to improve maternal and children health, childhood injury prevention, school readiness, juvenile delinquency, family economic factors, and coordination of community resources.

Putting Knowledge Into Practice: Funding

Prevention set-aside in mental health block grant. The Prevention and Public Health Fund

administered by the Office of the Secretary at HHS will support wellness and disease prevention activities authorized by the Public Health Services Act at an unprecedented level.

Nationally, this new fund will provide $15 billion for public health programs over 10 years.


Braided funding Fund state, county, and local prevention

and promotion networks State and local governments & community-based

agencies will be eligible to compete for a number of grants.

Community Transformation Grants will be available for activities that reduce chronic disease rates, prevent the development of secondary conditions, address health disparities, and improve the evidence base for prevention


Target resources to communities with elevated risk factors

Facilitate researcher-community partnerships

Prioritize use of evidence-based programs and promote rigorous evaluation across range of settings

Putting Knowledge Into Practice: Data Collection and Monitoring

HHS should provide annual prevalence data and data on key risk and protective factors

SAMHSA should expand service use data collection

Putting Knowledge Into Practice: Workforce Development

HHS, ED, and Justice should develop training guidelines

Set aside funds for competitive prevention training grants

Professional training programs should include prevention

Certification and accrediting bodies should set relevant standards

Continuing a Course of Rigorous Research:Overarching Recommendations

NIH should develop comprehensive 10-year prevention and promotion research plan

Research funders should establish parity between research on preventive interventions and treatment interventions

Continuing a Course of Rigorous Research: 10-Year Priorities

Prevention (specific disorders and common risk factors) and promotion

Replication, long-term outcomes, and multiple groups

Collaborations across institutes and agencies for developmentally related outcomes

Further improve current interventions

Continuing a Course of Rigorous Research: 10-Year Priorities

Guidelines and funding for economic analyses

Etiology and measurement of developmental competencies

Effectiveness of mass media and internet interventions

Address research gaps in populations and settings

Additional Information

Report available at: http://www.nap.edu

Summary available as free download Search the full report on line

Documents

Risk Factors are not predictive factors due to protective factors Carl C. Bell, MD Prospects for the Prevention of Mental Illness: New Developments and