Improving Behavioral Health in Young People: It Is Time for Social Work to Adopt Prevention

Abstract

Behavioral health problems in young people are often addressed through costly and ineffective treatment, rehabilitation, and control strategies aimed at helping children and adolescents after problems are identified. Evidence indicates that many behavioral health problems can be prevented before they occur, thereby saving significant individual, economic, and social costs. Although policy, practice, and research in reducing behavioral health problems have increased dramatically in the past several decades, social work has been slow to join other disciplines in the critical debate about the most effective and humane ways to prevent behavioral health problems. It is time for social work to adopt prevention as a guiding framework for practice, policy, advocacy, and research in behavioral health settings.

Keywords

behavioral health prevention social work children adolescents

Behavioral health problems exact significant individual, social, and economic costs on millions of young people in the United States. The most prevalent behavioral health problems include mental health symptoms of anxiety and depression; alcohol, tobacco, and other drug abuse; delinquent conduct; aggression and violence; school dropout; and risky sexual activity. The costs associated with adverse behavioral health outcomes are high. Underage drinking costs in the United States are estimated to be as high as US$27 billion per year, and delinquent behavior costs the nation US$60 billion per year (Kuklinski, Briney, Hawkins, & Catalano, 2012). Each year, more than 6 million young people receive treatment for mental, emotional, or behavioral problems. The annual financial costs for treatment services and lost productivity attributed to behavioral health problems are estimated at US$247 billion (O’Connell, Boat, & Warner, 2009). Other costs are incalculable, as parents, teachers, social workers, physicians, child psychiatrists, child welfare workers, juvenile justice probation officers, and communities struggle to combat the adverse effects of individual suffering, lost potential, and fraying social conditions.

Behavioral health problems also reflect and perpetuate social inequities. Social groups characterized by gender, race, ethnicity, citizenship, sexual orientation, and class experience dramatically different levels of behavioral health problems. For example, almost 83% of American Indian and Alaskan Native deaths are attributed to behavioral health problems (Hoyert & Xu, 2012). In 2014, U.S. homicide rates were more than 6 times higher for young males than females and 20 times higher for African American youth compared to non-Hispanic White youth (Child Trends, 2017).

For decades, federal, state, and local public policies have focused on protecting, treating, rehabilitating, and, often, controlling young people with identified behavioral health problems (Catalano, 2007). Billions of dollars are committed annually to programs and policies that treat and confine youth who experience mental health difficulties or engage in delinquent, aggressive, or substance-abusing behaviors (Catalano et al., 2012; Elliott & Fagan, 2017; Jenson, 2010; Jenson & Bender, 2014; Woolf, 2008). Evidence suggests that these programs and policies have not led to significant population-level reductions in behavioral health problems; rather, they have increased social inequity by contributing to well-known ethnic and racial disparities in rates of problem behaviors (Gilman, 2014; Western & Pettit, 2010). Treatment, rehabilitation, and control strategies are necessary to help and protect young people and ensure public safety. However, more than 30 years of research on prevention programs and policies shows that we can effectively prevent behavioral health problems from developing in the first place.

The Power of Prevention

Prior to 1980, few preventive interventions for behavioral health problems had been tested, and virtually no effective preventive interventions had been identified in the United States (Berleman, 1980). That changed in the 1980s when a small group of social scientists and advocates turned to the public health field for ideas about the best ways to prevent problems experienced by young people (Coie et al., 1993). Public health experts had long recognized the value of identifying the individual and environmental characteristics, conditions, and behaviors that predict illness and disease. National campaigns to inform the public of risks for and protective factors against cardiovascular disease—as well as new state and local policies and regulations—led to considerable reductions in cardiovascular risk factors such as smoking (Vuolo, Kadowaki, & Kelly, 2016). Identifying risks for and protective factors against health problems such as diabetes had helped countless individuals prevent, detect, or manage their diseases (Selvin, Parrinello, Sacks, & Coresh, 2014). A risk-and-protection focus had prevented illness and disease in medical settings. Thus, the central question for prevention became whether a similar risk-and-protection focus would be effective in preventing common child and adolescent behavioral health problems such as substance abuse, delinquency, violence, and school dropout.

Youth development advocates and prevention educators, practitioners, and researchers met this question with great enthusiasm and optimism. In fact, a framework that accounted for the presence or absence of risk and protective factors for child and adolescent problem behaviors seemed an ideal theoretical and implementation fit for many early intervention developers (Botvin, 2004; Greenberg, 2010; Hawkins, Catalano, & Miller, 1992). By 1990, a risk-and-protection approach to preventing behavioral health problems was receiving significant attention from investigators in psychology and public health. However, adoption of a public health framework in social work, with several notable exceptions (e.g., Hawkins, 2006; Jenson & Fraser, 2016), was relatively slow.

Significant advances in prevention have been made in the past three decades. Today, more than 65 effective individual, family, school, and community prevention programs for behavioral health problems have been identified at universal, selective, and indicated levels of implementation (Blueprints for Healthy Youth Development, 2019; Elliott & Fagan, 2017; Jenson & Bender, 2014). This evidentiary base provides a readily available foundation for social work to expand its role in prevention. However, prevention principles and frameworks are seldom taught in schools of social work, and evidence supporting effective preventive programs and policies is not disseminated or applied widely in social work practice, policy, or research (Hawkins, Shapiro, & Fagan, 2010; Jenson & Hawkins, 2018).

Social Work and Prevention: A Call to Action

Social work’s reluctance to embrace prevention is perplexing. After all, social work has a long-standing tradition and a rich history of addressing the underlying social conditions that lead to the onset of individual and social problems (Almgren, Kemp, & Alison, 2000). In addition, social work’s history of using social-ecological theories to guide epidemiological assessment of the social determinants of behavior is consistent with the dominant prevention practices, programs, and policies that promote positive behavioral outcomes (Bronfenbrenner, 1979). The profession’s commitment to multilevel practice also creates and recognizes opportunities for practitioners to help individuals make positive choices that lead to healthy behavior. This commitment provides a strong underlying context for organizations to adopt and implement effective prevention programs and for communities to organize local services that promote social justice and equity.

The foundation and core principles underlying social work are a natural fit for prevention practice, policy, and research. Yet, on the whole, social work is underrepresented in state and federal policy discussions that lead to decisions about how resources are allocated to promote behavioral health. Furthermore, the frameworks and evidence that inform today’s prevention practice and policy strategies are seldom taught in schools of social work (Hawkins et al., 2010). The lack of prevention content in social work education is even more puzzling when one considers that students graduating with social work degrees are ideally positioned to design, deliver, and evaluate programs that seek to prevent behavioral health problems in young people.

How do we increase social work’s interest, commitment, and capacity in prevention practice, policy, and research?

Increase Educational Content in Prevention

Increasing social work’s involvement in prevention begins with education. Although there are approximately 20 interdisciplinary prevention science training programs in the United States, none of these programs are located in departments or schools of social work (Society for Prevention Research, 2019). More troubling is evidence suggesting that prevention content is seldom integrated in social work foundation classes or offered in advanced concentrations in master of social work training (Shapiro & Bender, 2018). The Council on Social Work Education (CSWE) does note the importance of prevention in several of its 2015 Educational Policy and Accreditation Standards (CSWE, 2019), and CSWE has published advanced practice standards in preventing substance use disorders (CSWE, 2009). However, these efforts are isolated and have not led to a groundswell of interest in prevention or to the widespread implementation of comprehensive prevention content in schools of social work.

Educational materials in prevention are available and ready to be implemented across all levels of social work education. One current effort to promote prevention education in social work is led by the Coalition for the Promotion of Behavioral Health (CPBH), which was created to advance prevention in social work through the Grand Challenges for Social Work Initiative (Jenson & Hawkins, 2018). Described further later, the CPBH has created four prevention education modules that address theories and principles of prevention practice and policy. The modules can be used as stand-alone instructional units or infused into social work foundation or concentration classes. Modules are free and available for download at the CPBH’s (2019) website (https://www.coalitionforbehavioralhealth.org). A second curriculum resource is available from the International Society of Substance Use Professionals, an interdisciplinary group of practitioners and researchers that focuses on the worldwide universal prevention of substance use. This comprehensive curriculum is available to the public and could be readily adapted for use in social work undergraduate and graduate courses. See the Society’s website (https://www.issup.net/training/universal-prevention-curriculum) for more information (International Society of Substance Use Professionals, 2019).

Social work is well positioned to produce the next generation of prevention practitioners in behavioral health and related fields. Recent changes in health-care practice and policy have greatly expanded the role of social work practitioners in behavioral health care. To illustrate, millions of dollars have been awarded to schools of social work by the U.S. Department of Health and Human Services Health Resources and Services Administration to train graduate students for practice in behavioral health settings. The opportunities afforded by these awards provide an excellent opening for schools of social work to add prevention content to the social work curriculum.

As future practitioners, social work students at all instructional levels should receive training in understanding the public health and ecological frameworks that guide prevention and social work practice. Courses that inform students about the intervention strategies, programs, and policies that have been tested and found to be effective in preventing behavioral health problems should also be designed and included at all levels of instruction. Field education, a particular strength of social work education, provides an additional platform to advance prevention practice and should be considered in efforts to increase prevention training in schools and departments of social work.

Expand Social Work’s Larger Role in Prevention Advocacy, Policy, and Research

Recognition as a field that is committed to prevention requires active participation in advocacy, practice, policy, and research at the local, state, and national levels. Providing opportunities for current and future social work advocates, practitioners, policymakers, and researchers to interact with prevention experts in other settings and disciplines is, therefore, key to increasing social work’s role in prevention.

One opportunity for advocates, practitioners, policymakers, and researchers to become involved in prevention is available through participation in the Grand Challenge to Ensure Healthy Development for All Youth—one of 12 Grand Challenges for Social Work championed by the American Academy of Social Work and Social Welfare (2017). The challenge to Ensure Healthy Development for All Youth includes an initiative called Unleashing the Power of Prevention (Hawkins et al., 2015; Jenson & Hawkins, 2018), which uses evidence from three decades of research examining the effects of preventive interventions to identify strategies necessary to prevent behavioral health problems in all young people. This grand challenge affords a number of opportunities to become involved in prevention.

The goals of Unleashing the Power of Prevention are to (a) reduce the incidence and prevalence of behavioral health problems in young people, from birth to age 24, by 20% and (b) reduce racial, socioeconomic, and other disparities in behavioral health problems by 20%. These goals were initiated in 2016 and are to be met by 2026. The framework includes seven action steps that are necessary to make meaningful and measurable progress in reaching these goals in the next decade (Hawkins et al., 2015; Jenson & Hawkins, 2018). These action steps call on social work and other disciplines to

develop and increase public awareness of the advances and cost savings of effective preventive interventions that promote healthy behaviors for all;

ensure that 10% of all public funds spent on young people support effective prevention programs;

implement community-assessment and capacity-building tools that guide communities to systematically assess and prioritize risk and protective factors and select and implement evidence-based prevention programs that target prioritized factors;

establish and implement criteria for preventive interventions that are effective, sustainable, equity-enhancing, and cost-beneficial;

increase infrastructure to support the high-quality implementation of preventive interventions;

monitor and increase access of children, youth, and young adults to effective preventive interventions; and

create workforce development strategies to prepare social work graduates and allied practitioners for new roles in promotion and preventive interventions (Jenson & Hawkins, 2018).

The CPBH was created in 2014 as the organizational entity responsible for implementing the action steps identified in the Unleashing the Power of Prevention report. To date, the CPBH has focused its work in three areas: (a) increasing community and state infrastructure for delivering preventive interventions for behavioral health problems; (b) scaling up tested, effective family-focused interventions in pediatric and health-care settings; and (c) preparing the social work workforce to deliver tested, effective preventive interventions for behavioral problems in children and youth. For a detailed description of these and other activities, see Jenson and Hawkins (2018) and the CPBH website (https://www.coalitionforbehavioralhealth.org), which includes the coalition’s strategic plan. The CPBH welcomes anyone interested in joining its efforts to use the power of prevention to promote positive behavioral health in young people.

Summary

Behavioral health in young people is among the nation’s most pressing concerns. Historically, efforts to combat behavioral health problems have concentrated on treating, rehabilitating, or controlling problems after they have been identified. Over 30 years of evidence now reveals that behavioral health problems can be prevented before they develop. Today’s challenge is to broadly implement this evidence at scale by delivering tested, effective programs and policies that reach all young people. It is time to use this evidence to create the training, programs, policies, and infrastructure that lead to the healthy development of all children and youth.

Social work should be active in efforts to prevent behavioral health problems and promote the healthy development of young people. Increasing social work’s involvement and role in prevention practice, policy, and research is a natural fit. The key theories and principles of prevention are aligned with the history, mission, and goals of social work. Furthermore, values of social justice and equity embedded in social work are evident in prevention’s commitment to reducing problems and promoting positive development among all youth, regardless of race, ethnicity, sexual orientation, or economic standing.

A new commitment to prevention education in schools of social work is needed to train and excite the next generation of prevention practitioners, policymakers, and researchers in the power of prevention. Changes in approaches to health-care delivery have created numerous career opportunities for social workers in behavioral health settings. To compete with students from other fields, social work graduates must have knowledge of the principles, frameworks, and evidence of effective prevention practice, policy, and research. Enhanced training in prevention at all levels of education would help level the playing field in the behavioral health workforce for social work graduates.

Social work has long been recognized as a field that effectively builds bridges among other disciplines and fields. Not surprisingly, collaboration is a key component of effective prevention practices and policies. Working collaboratively with other fields and disciplines, social work practitioners can serve as coordinating hubs for shared efforts to prevent behavioral health problems. Social workers trained in advocacy and policy can also bring together community residents and professionals to shape local education, health, and human service delivery and state and national initiatives to unleash the power of prevention. Together with allied professions, social work researchers can help ensure that tested and effective preventive interventions are supported by parallel initiatives in health care, education, public health, mental health, child welfare, and juvenile justice (Herrenkohl, in press; Jenson & Fraser, 2016). Finally, social workers can actively advocate for increased emphasis on preventing behavioral health problems in federal, state, and local policies and budgets.

Now is the time for social work to reactivate its long-standing and historical commitment to prevention.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jeffrey M. Jenson

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