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date: 19 January 2020

Investments in Children’s Mental Health

Summary and Keywords

One of the most important unanswered questions for any society is how best to invest in children’s mental health. Childhood is a sensitive and opportune period in which to invest in programs and services that can mitigate a range of downstream risks for health and mental health conditions. Investing in such programs and services will require a shift from focusing not only on reducing deficits but also enhancing the child’s skills and other assets. Economic evaluation is crucial for determining which programs and services represent optimal investments. Several registries curate lists of programs with high evidence of effectiveness; many of these programs also have evidence of positive benefit-cost differentials, although the economic evidence is typically limited and uncertain. Even the programs with the strongest evidence are currently reaching only a small fraction of young people who would potentially benefit. Thus, it is important to understand and address factors that impede or facilitate the implementation of best practices. One example of a program that represents a promising investment is home visiting, in which health workers visit the homes of new parents to advise on parenting skills, child needs, and the home environment. Another example is social emotional learning programs delivered in schools, where children are taught to regulate emotions, manage behaviors, and enhance relationships with peers. Investing in these and other programs with a strong evidence base, and assuring their faithful implementation in practice settings, can produce improvements on a range of mental health, academic, and social outcomes for children, extending into their lives as adults.

Keywords: health economics, mental health, children, economic evaluation, policy, implementation

The Need for Investments in Children’s Mental Health

The past several decades in the U.S. and many other countries represent, for the most part, a public health success story. Life expectancy at birth in the U.S. increased by over six years in the span of two decades to reach 78.8 years in 2015 (NCHS, 2017). As of 2018, people in the U.S. and many other countries are healthier and live longer than at any point during human history. The situation is much worse, however, for people with poor mental health; persons living with a mental disorder die on average 8.2 years younger than others in the population (Druss, Zhao, von Esenwein, Morrato, & Marcus, 2011). Mental and substance use disorders now account for a higher burden of disability than any other set of conditions worldwide (Whiteford et al., 2013).

What can be done to prevent such population-level morbidity and mortality stemming from mental health? One obvious response is to intervene early by making investments in improving the mental health and well-being of children. Addressing the mental health needs of children involves both identifying and treating disorders in childhood, as well as preventive strategies focused on enhancing children’s cognitive and emotional skills and other assets (Zeanah, 2009).

There are many advantages to addressing mental health early in life. Mental disorders often start during childhood and then persist into adulthood, and many risk factors for adult-onset mental disorder occur during childhood (Werner, 2004). Early intervention expands the options for both treatment and prevention. Children can be influenced positively in many ways through their rich social context, or “social ecology,” including families, peers, schools, and communities (Earls & Carlson, 2001). Furthermore, there is evidence that mental health problems are on the rise among children and adolescents, and this may be exacerbated by the rising use of social media and mobile technology (Twenge, Joiner, Rogers, & Martin, 2018). These recent trends highlight the urgency of addressing the mental health needs of young people.

While the intuitive appeal of early intervention for mental health is clear, the practical steps are not. A better understanding is needed of which investments are best, the extent to which those investments are currently being made, and how scholars and policymakers can bridge the gap between evidence and practice. The research evidence has important uncertainties; for example, for most potential investments it is unclear what the longer-term, lifelong outcomes are. Even when programs and services have clear-cut evidence of lasting benefits, exactly how to deliver these interventions is not fully clear. On average, it takes 17 years for known, efficacious interventions to be deployed widely in clinical practice (Balas & Boren, 2000). Another complication arises from the fact that children are served by many sectors, both public and private, including schools, healthcare, child welfare, and juvenile justice; it is therefore difficult to coordinate a coherent approach to treatment and prevention, and children run the risk of falling between the cracks. This is even truer in countries such as the U.S. with highly decentralized education, healthcare, and other social service systems.

This manuscript lays out an agenda for understanding the opportunities to invest more effectively in children’s mental health, and points to opportunities for the field of economics to contribute to future research alongside other relevant disciplines. The discussion focuses primarily on the U.S. context, but much of the information could have relevance to other countries confronting similar challenges. A better understanding of this topic is crucial for several different audiences. Leaders and decision-makers, such as policymakers and administrators, need to know which specific investments to consider funding and implementing, and should have a general framework and process by which to evaluate what makes a good investment and how to implement it successfully. Practitioners such as mental health professionals and teachers need to know which programs and practices to advocate for and how they can support successful implementation. Finally, scholars need to increase their understanding and appreciation of the important gaps that remain in our knowledge in this area. These questions require far more talent, time, and energy from the scholarly community, and greater coordination and collaboration across disciplines including economics.

Conceptual Framework: What Does It Mean to Invest in Children’s Mental Health?

This section explores conceptually, from a multidisciplinary perspective, what it means to invest in children’s mental health. This conceptual foundation is necessary for identifying optimal strategies to improve mental health in a society. In particular, the meaning of “mental health” and “investment” is examined, along with the developmental and social-ecological contexts that influence children’s mental health.

Defining Children’s Mental Health

Whereas discussions of mental health often focus on disorders such as depression and schizophrenia, this article uses broad, holistic definitions, which acknowledge the wide range of potential opportunities to improve young people’s well-being through their mental health. For example, the World Health Organization (WHO) defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO, 2004). A child displaying well-being masters developmental milestones and is without disorder, and also engages with the world in a childlike way—displaying curiosity, spontaneity, and play (Raghavan & Alexandrova, 2015). This definition leads to consideration of not only investments that reduce or prevent negative symptoms but also those that promote positive skills and functioning.

Economic Framework

A microeconomic perspective is also useful for considering how health investments fit into an individual’s life cycle. Standard models of human capital, and of health capital, posit that these concepts are assets that yield benefits (in terms of productivity and well-being) but depreciate over time (Grossman, 1972). Thus, investments in human and health capital allow people to build up these assets, whereas other forces, along with natural depreciation due to time and age, reduce the assets.

Best investments can be defined in many different ways. There is, however, a set of standard practices in economic evaluation that can be applied to this context. These practices are embodied by tools such as benefit-cost analysis, cost-effectiveness analysis, and return-on-investment analysis, all of which share the same general purpose: to quantify the total net benefits that can be derived from a limited set of resources. These tools are based on a utilitarian philosophy of social welfare, in which the objective is to maximize the total social benefit regardless of the distribution of those benefits. This underlying assumption represents one of several reasons why the results of economic evaluations should be considered an important guide but not a sole, definitive answer to investment decisions.

Approaches to economic evaluation can differ significantly in the perspectives they take. A narrower perspective limits its focus to the net economic benefits for a particular organization or payer, such as a school, community, insurance program, or the government budget. A broader perspective, the “societal perspective,” considers all benefits and costs affected by an investment decision, regardless of who is responsible for paying or who benefits. Analyses can also differ in their time horizon, which has important implications for investments that target young people with the hope of improving their lifetime outcomes. In most situations, it is useful to examine results from multiple perspectives: the long-term, societal perspective typically represents the ideal, whereas the short-run organizational or public budget perspective acknowledges real-world constraints regarding decision-making processes.

Economic evaluation is especially important in the context of children’s mental health, because resources are typically very limited relative to the needs in populations (NRC-IOM, 2009). The continued development and application of such evaluations must confront several challenges inherent to the context of children’s mental health. The fact that children’s mental health affects several different sectors—including education, healthcare, juvenile justice, and child welfare—brings difficult challenges related to measurement of outcomes and alignment of incentives (Knapp, 1997). Another important challenge is quantifying the long-term benefits and costs of childhood interventions; such projections typically rely on a number of assumptions, as there are few randomized trials that follow children into adulthood (and even in those cases, one must consider whether the results generalize across generations).

The Child Within a Social Context

Mental health influences, and is influenced by, nearly every imaginable aspect of children’s lives, and therefore can only be properly examined through a broad, multilayered perspective. This begins with understanding a child’s social ecology, which acknowledges the many nested layers of influence around young people’s lives (Fraser, 2004). Clearly, children possess internal resources that enhance or diminish their vulnerabilities—such factors include their level of intellectual development and resilience skills. There are also other key factors outside the child that influence their development. These may be interpersonal (e.g., friendships, relationships with parents and teachers), factors at the classroom and school level (e.g., resources, attitudes, expectations), and community-level and societal-level factors such as public policies and programs, neighborhood safety, economic inequality, and corporate marketing. Especially for young children, a caregiver who can provide a safe and secure attachment is of vital importance (Shonkoff & Garner, 2012). Each level of influence points to a set of potential risk and protective factors, with accompanying intervention strategies.

Levels of influence can interact with each other in this perspective, highlighting the interrelationships and overlap between risk and protective factors and intervention strategies. For example, the Positive Action socio-emotional school-based program emphasizes internal processes, as embodied in its thoughts-feelings-actions framework, as well as interpersonal relationships, such as treating others the way you like to be treated. Thus, alternative intervention strategies do not necessarily correspond to a single level within a social-ecological framework.

Developmental Perspective

While the social-ecological perspective more or less represents the space continuum surrounding young people’s mental health, the developmental perspective represents the time continuum. The needs and capacities of young people change over time, often dramatically so (Masten, 2001). The same external adversities affect children of different ages differently, the capacity to overcome these adversities changes over time, and the ability to respond to interventions—and the types of intervention required—consequently also vary at different stages of development. The process of growing also brings new challenges and expectations, such as substance use and other risky behaviors that emerge in adolescence.

Integrating These Perspectives

These perspectives must be woven together to understand opportunities for investing more effectively in children’s mental health. A holistic definition of mental health and well-being, in combination with the basic principles of economic evaluation, form the basis for how this article defines best investments. The social-ecological and developmental frameworks provide a map for which interventions are available and how those interventions might fit together in combinations within communities and society more broadly.

Overview of Evidence and Practice

Evidence on Best Investments

To identify best investments in children’s mental health, a logical starting point is the research and evaluation evidence on what works to improve outcomes. There is increasing recognition that most programs do not work to achieve their intended outcomes; thus, there has been increasing support for the ideal of evidence-based policy and practice for social programs in the U.S. (Haskins & Margolis, 2014).

Of course, it is no simple matter to sort programs into those that work and those that do not, let alone quantify exactly how well programs work. Questions arise as to what qualifies as evidence. There is also the need to represent accurately the inevitable uncertainty surrounding any piece of evidence; this uncertainty is often much greater than decision-makers and even researchers realize or acknowledge (Manski, 2013). In children’s mental health, as in any other area, reliable evidence on the ability of programs to work and truly represent best investments is needed, before decisions can be taken regarding their widespread implementation.

There are a number of registries that synthesize and summarize evidence on programs related to children’s mental health. These registries are an ideal starting place for someone looking for a list of effective programs or a summary of evidence on specific programs. The registries typically focus on evidence for effectiveness, but in some cases they also include information about economic returns.

One leading example focused on children and youth is the Blueprints registry. Blueprints classifies programs into Promising, Model and Model Plus categories. In order to be a Promising program, the intervention must meet the following criteria: subjected to one randomized control trial (RCT) or two quasi-experimental evaluation studies; displayed intended treatment effects; displayed no harmful treatment effects; and must be ready for dissemination. Model and Model Plus programs are backed by two RCTs or one RCT along with a quasi-experimental evaluation, and display sustained treatment effects for at least a year. In addition, in order to receive a Model Plus designation, these programs also must have been independently replicated. All programs evaluated by Blueprints require that the intervention is fully developed—with a specific population, and intended treatment effects and mechanisms, as described in a logic model. Blueprints is comprehensive in that it considers a wide range of programs related to children’s and youth development (over 1,400 programs assessed to date). Most other registries have more liberal or flexible criteria for inclusion, as compared to Blueprints, and therefore may include more programs with promising but uncertain evidence.

Registries serve a variety of information seekers, and therefore display great heterogeneity in evaluation, organization, and presentation of information. Most are designed for administrators (such as executive directors of agencies considering program expansions), professionals and providers (who may be enhancing their own skill sets), payers (who may be deciding whether or not to pay for services and programs), and policymakers in mental health, social service, and child health departments and divisions, who may be seeking greater regulatory authority on what to deliver to their covered lives. Because registries aggregate programs that vary in terms of their population served (children or adults, for example), registries are inherently heterogeneous. Aside from Blueprints, examples of other registries include the National Institute for Justice (NIJ)’s; Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Registry of Evidence-Based Programs and Practices (NREPP); the Department of Education’s What Works Clearinghouse; the Laura and John Arnold Foundation’s Social Programs that Work; and guides to social and emotional learning (SEL) programs by the Collaborative for Academic, Social, and Emotional Learning (CASEL).

These registries have all focused on the U.S. context, although some such as Blueprints do include a small number of programs that have primarily been developed and tested in other countries. There are few if any registries that focus on children’s health and well-being and have a fully international scope. Thus, for those who wish to consider a context outside the U.S., the options as of this writing appear to be either to make do with a U.S.-focused registry or else to search through an international registry with a scope much broader than children’s mental health (e.g., the Cochrane Collaboration, the Campbell Collaboration, or the Centre for Reviews and Dissemination (CRD)) (Burkhardt, Schroeter, Magura, Means, & Coryn, 2015).

For economic evidence specifically, the most comprehensive registry of social programs is produced by the Washington State Institute for Public Policy (WSIPP, 2018). On behalf of the state government in Washington, WSIPP conducts cost-benefit analyses, based on the best available studies and data, for social and health programs, including many programs targeted to children and adolescents. WSIPP is unique in the breadth of the programs and services that it evaluates using a uniform framework for economic evaluation. One caveat is that it uses data specific to Washington State, to the extent possible. This is not necessarily a major limitation, however, because the main conclusions for economic evaluations of programs targeted to young people depend primarily on the effect sizes for key outcomes related to education, health, and crime. These types of outcomes generally have large economic consequences regardless of local parameters. A more important caveat is that WSIPP focuses on quantifying economic costs that can be most readily quantified. Thus, it does not attempt to assign monetary value to health and well-being per se; rather, it assigns economic returns to health and well-being measures only to the extent that they have been shown to predict other outcomes such as educational attainment, employment, and criminal activity. This approach is consistent with a focus on the perspective of a state government’s budget, but means that some of the results might substantially understate the full societal benefits of programs and services focused on young people’s mental health.

Practice in the U.S. in the 21st Century

To what degree does policy and practice in the U.S. reflect the evidence on best investments in children’s mental health? This question is surprisingly difficult to answer, because there is only a patchwork of information, with no unified databases, on levels of funding and penetration of relevant programs and services. Improving this availability of information would be an important advance in its own right.

While comprehensive databases on practice are lacking, it is evident from simply examining a handful of programs that the gap between research and practice is large. For example, for each “Model” program in the Blueprints registry for which estimates are available, the national penetration represents only a small fraction of the population that could potentially benefit. For elementary school-based SEL programs that are rated Model—Positive Action and Promoting Alternative Thinking Strategies (PATHS)—the national reach is less than 3% of schoolchildren (Neuhoff, Loomis, & Ahmed, 2017). Similarly, Multisystemic Therapy (MST) reaches an estimated 12,000 young people per year (Neuhoff et al., 2017), which is impressive in absolute terms but very small relative to the hundreds of thousands who might benefit. For school-based substance use prevention programs, only about a quarter of schools use an evidence-based program (such as Life Skills Training) as their most frequently delivered program (Ringwalt et al., 2011). Thus, although the data are far from complete, it is clear that the research–practice gap consists of both underinvestment in evidence-based programs and overinvestment in programs without strong evidence.

Barriers and Facilitators to Implementation

Implementation has been defined as a “set of activities necessary to successfully and sustainably apply with high fidelity an intervention of known efficacy within community-based clinical settings” (Raghavan, Bright, & Shadoin, 2008, p. 26). The key lesson, especially in the context of health and mental health interventions, is that implementation activities are contextual and not solely clinical. Implementation involves the encounter with a health professional, the organization within which services are delivered, the regulatory and funding environment, and the broader political and social milieu. Consequently, facilitators and barriers to implementation are contextual, and institutional frameworks and organizational factors can guide implementation efforts (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Glisson & Green, 2006; Schoenwald & Hoagwood, 2001).

An economic perspective is essential for understanding implementation issues, as financial facilitators and barriers to implementation are of great importance. Implementation is conditional upon access to services, and so strategies that finance the utilization of mental health services (such as health insurance; see Kataoka, Zhang, & Wells, 2002), or factors that can facilitate access (such as healthcare navigators that can link patients to services) are necessary but insufficient facilitators of successful implementation. As of the early 2000s, fiscal implementation strategies began to focus narrowly on supporting evidence-based interventions—these include providing financial incentive for delivery sites, repurposing block grants, making Medicaid billing easier, and guidelines to support best practices (Magnabosco, 2006). For example, providers in North Carolina who are on a roster based on demonstrated expertise can bill at an enhanced rate when they deliver trauma-focused cognitive behavior therapy, a specific intervention for psychological trauma (Partners Behavioral Health Academy, 2016).

Funding for children’s mental health faces several difficult challenges. First, the funding and financial incentives are mostly focused on treatment services; the funding available for mental health promotion and prevention programs is much less (NRC-IOM, 2009; Saxena, Thornicroft, Knapp, & Whiteford, 2007). Second, because children are often served by several sectors (education, healthcare, child welfare, etc.), funding streams and incentives are rarely integrated. In fact, fragmentation also affects children when they transition from child-serving to adult-serving systems of care, usually between the ages of 18 and 21. Children on public insurance display insurance discontinuities and tend to lose their insurance coverage when they leave the child welfare system as adults, leaving many of them without the ability to secure needed services (Raghavan, Allaire, Brown, & Ross, 2016; Raghavan, Shi, Aarons, Roesch, & McMillen, 2009).

Financial strategies can be used not only to support needed and evidence-based interventions, but also to stop harmful or outdated interventions. This systematic cessation of interventions is called de-implementation (Norton, Kennedy, & Chambers, 2017; Prasad & Ioannidis, 2014). At the time of the writing, there is little literature on how financial levers can drive a de-implementation agenda, but this will likely emerge as an important area of inquiry in the future.

Two Illustrative Examples

In this section two types of programs that appear to be good investments in children’s mental health are highlighted in greater depth. These examples illustrate further some of the challenges and opportunities with respect to moving toward better investments as a society. The information in this section is drawn mainly from a review of published reports and data, supplemented by interviews of experts in these areas.

Example #1: Home Visiting Programs

Among the many provisions of the 2010 Affordable Care Act was an amendment of Title V of the Social Security Act, creating the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Perhaps the largest ever investment in home visiting, the MIECHV program was funded at $1.5 billion in total for a total duration of five years. In doing so, the Obama Administration was supporting a program with a long history in American social policy. Visitors have been traveling to, and inspecting, the homes of low-income individuals with children since the late 1800s (Weiss, 1993). The initial forays were broadly instructional; the visitors were role models for the visited to emulate. By the 1960s, though, the emphasis of home visiting had shifted to improving specific children’s outcomes. By 2009, states were investing between $500 million and $750 on various home visiting programs, in which nurses and other professionals were collectively serving more than a half a million children (Avellar & Supplee, 2013).

The appeal of an intervention focused on enhancing assets of low-income children and their mothers during the immediate postnatal period is easy to understand. Experiences in early life—whether adverse or positive—have significant effects on health, mental health, and development in later life (Garner, 2013; Shonkoff & Phillips, 2000). These effects include physical growth and development, physical health, and healthy psychological development, including cognitive development, learning, and emotional regulation. These effects are mediated through a set of complex neurobiological and physical processes.

Mothers represent perhaps the single most important influence in the animal kingdom when it comes to child well-being, a fact perhaps demonstrated most poignantly by Bowlby in his experiments with infant monkeys reared by wire monkey mothers (Bretherton, 1985). Secure attachment to a parental figure is critical to infant and early childhood mental health (Zeanah, 2009). By intervening at a critical developmental period with low-income mothers, home visiting programs offer the potential to alter the trajectories of the most disadvantaged children, and to narrow the gap between these children and their better-off peers. Home visiting, therefore, is a type of “social vaccine,” a preventative strategy directed at a child’s family context that can forestall a range of downstream problems for the most disadvantaged of children.

Home visiting is an umbrella term that encompasses a heterogeneous, but overlapping, set of components (Filene, Kaminski, Valle, & Cachat, 2013). Some of these components include education about normal child development and building parental skills in child-focused activities (e.g., diapering, appropriate disciplinary strategies); ensuring that the home environment is most conducive to child development (e.g., increasing the safety, enrichment, and cleanliness of the home); measuring and promoting the child’s socioemotional and cognitive development; directly providing, or helping facilitate, social services to the parent and other forms of case management; helping parents with their own needs (substance use, health and mental health needs, and relationship enhancement); and assisting parents with finding informal supports. The home visiting program may also display design differences—for example, programs may use nurses, psychologists, social workers, or lay health workers as visitors; either use a manualized model or be more responsive; and may engage with the parents at different frequencies, and for differing durations.

The Department of Health and Human Services in 2009 established the Home Visiting Evidence of Effectiveness project, which provides systematic information on the evidence base for these programs on a public website. This project concluded that 20 (out of 45) home visiting programs met federal criteria for evidence of effectiveness. These criteria focus on the quality of study designs and whether the programs demonstrate positive effects on one or more of a set of eight possible outcome domains. Most of these 20 programs produced improvements in the child development and school readiness, and positive parenting practices domains. A smaller number improved maternal and child health, and reduced the risk of child abuse and neglect.

A systematic review by Peacock, Konrad, Watson, Nickel, and Muhajarine (2013) suggests that the most effective programs are those that have a high dosage (i.e., more frequent interventions sustained over longer periods of time), that intervene with mothers before the birth of the child, that have well-trained staff, and where the program is tightly focused on a few objectives rather than being diffuse. Delivering the intervention over a long duration also appears to be key in another important way. Families at risk rarely face a single crisis; instead, they face crises that are different in content, involving novel situations and circumstances. Such “cyclical crises” require a degree of responsiveness, which can only be achieved in long-standing programs (Yonemoto, Dowswell, Nagai, & Mori, 2014).

Among specific home visiting programs, the Nurse-Family Partnership is perhaps the best known (Olds, 2006), and it is the only visiting program meeting the evidence criteria for a Model program in the Blueprints registry. The economic case for this program appears to be quite favorable (Miller, 2015). To address some of the lingering questions that have been raised about the program’s evidence, Heckman, Holland, Makino, Pinto, and Rosales-Rueda (2017) re-examine the Memphis randomized trial of the Nurse-Family Partnership, and conclude that many of the estimated benefits for child development are robust to adjustments for randomization design and multiple hypothesis testing.

The largest evaluation of effectiveness of home visiting programs is still in the field as of 2018. Called the Mother and Infant Home Visiting Program Evaluation (MIHOPE), this national evaluation is a randomized clinical trial involving 12 states, 85 local implementing agencies, and 5,100 pregnant women or families with infants, 6 months of age (Michalopoulos et al., 2015). The evaluation includes four home visiting models selected by states that are utilizing MIECHV money. The evaluation will provide important information on the economic cost and, consequently, an economic evaluation of the considerable investments that have been made in home visiting over the past decade.

What, then, is the state of the evidence that underpins home visiting? Is it a program of uncertain and modest efficacy? Does the $1.5 billion allocated to MIECHV represent a good investment of public money? It seems that home visiting programs that have particular design characteristics and that are delivered in particular intensities have positive effects for many health and developmental outcomes for children. Hence, the best investments are those that privilege certain program components, delivered by particular visitors, accompanied by a careful measurement of a narrower set of outcomes. The MIHOPE evaluation, when completed, will provide valuable information on the cost effectiveness of home visiting, which will be an important factor informing the task of how best to change developmental trajectories of some of the most disadvantaged of this nation’s children.

Example #2: School-Based SEL Programs

Schools represent another promising context by which to invest in children’s mental health. In recent years, educators in the U.S. and many other countries have paid increasing attention to possibilities for promoting in children’s SEL, as complements to traditional academic skills. SEL consists of five types of skills related to emotions, behaviors, and interpersonal relationships, according to the Collaborative for Academic, Social, and Emotional Learning (CASEL) (Weissberg, Durlak, Domitrovich, & Gullotta, 2015): self-awareness, self-regulation, interpersonal awareness, relationship skills, and positive decision-making.

SEL has strong links to mental health outcomes, both theoretically and empirically. A common SEL theoretical framework emphasizes a series of steps for dealing with emotions: recognize, understand, label, express, and regulate (Brackett, Elbertson, & Rivers, 2015). SEL skills during childhood are predictive of mental health symptoms and conditions such as depression, as well as a wide range of academic, social, behavioral, and other health outcomes in later childhood, adolescence, and adulthood (Jones, Greenberg, & Crowley, 2015a).

There is a growing base of evidence indicating a range of positive effects for SEL programs. A widely cited meta-analysis from 2011 reviewed over 200 school-based SEL programs, and found significant improvements in social and emotional skills, attitudes, behavior, and academic performance (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). A more recent meta-analysis built on the earlier one by addressing follow-up effects (Taylor, Oberle, Durlak, & Weissberg, 2017); they reviewed 82 studies, mostly RCTs, of school-based SEL programs with follow-up outcomes six months or more after the intervention period, and again found significant effects, mostly in the range of 0.15–0.30 effect sizes, for nearly all of the outcomes they examined.

Although the meta-analyses are frequently cited to support the effectiveness of SEL on a broad level, all programs are not equal, of course. Two programs, PATHS and Positive Action, are recognized as Model programs according to the Blueprints registry, each with multiple high-quality RCTs demonstrating effectiveness. In addition to these two programs, several other programs are highlighted in the Handbook of Social and Emotional Learning as meeting criteria for “what works”: at the pre-school level, Incredible Years; at the elementary level, Second Step, Caring School Community, and Responsive Classroom; and at the middle school level, Life Skills Training and Responding in Peaceful and Positive Ways (RIPP). At the high school level, no programs meet the full criteria for “what works,” but several were designated as promising. At the postsecondary level, mindfulness interventions were recognized as a category of program with consistently positive results. Many other programs are in the “promising” category at all levels of education.

Although there is plenty of evidence supporting the effectiveness of SEL programs, there are still important limitations in the research. Positive outcomes are often teacher-reported and focused on subjective skills rather than objective behaviors. As in the general child development literature, fadeout of initial effects is a concern. The recent meta-analysis addresses this issue to some degree, but most studies had no more than one- or two-year follow-up periods. In addition, the mechanisms for positive effects of SEL programs are not entirely clear. For example, most programs are integrated with academic content, and it is difficult to disentangle effects of that academic content versus SEL-specific skills.

Based on the generally encouraging evidence for effectiveness of SEL programs, a small number of studies have extrapolated to an economic case. The WSIPP estimates, for example, that both Positive Action and PATHS have very favorable benefit-cost differentials per individual: $14,002 benefits versus $444 costs for Positive Action, and $7,487 versus $360 for PATHS. Another report uses the best available data to assess the benefit-cost ratios for several prominent SEL programs (Belfield et al., 2015): 4Rs, Positive Action, Life Skills Training, Second Step, Responsive Classroom, and Social and Emotional Training. They find favorable benefit-cost ratios for this set of programs as a whole, and they emphasize that any variation in their results across programs should not overemphasized, as it can result from differing availability of measures that can be translated into economic benefits. For Positive Action, for example, they estimate costs per participant of $510, compared to benefits of $2,580. They also discuss the methodological challenges and areas for improving this line of research. Similarly, Jones, Greenberg, and Crowley (2015b) discuss the strengths and limitations of economic evidence for SEL programs, and identify the biggest challenge and area for improvement as monetizing proximate outcomes commonly produced by SEL programs. This is particularly difficult for younger children, such as elementary schoolchildren, because there are few solid estimates of how their outcomes translate into longer-term economic consequences.

To consider the future of SEL programs, it is important to take stock of the present situation. There has unquestionably been a substantial increase in attention to SEL. Experts interviewed by one of the authors of this article point to several factors to explain the enthusiasm. First, SEL is consistent with basic principles that have been around for many decades, only under different names. As one expert noted, SEL is simply an essential feature of high-quality teaching: high-quality interactions and relationships with kids that undergird conversations about academic content. Second, a critical mass of research evidence has been built, as reflected in the meta-analyses described. Third, there is a growing appreciation in society more broadly for the importance of “soft skills” in determining social and economic success in life. Several prominent scholars have brought these ideas into popular and policy conversations, such as Duckworth’s emphasis on grit (Duckworth, Peterson, Matthews, & Kelly, 2007), Dweck’s study of growth mindsets (Dweck, 2017), and Heckman’s focus on non-cognitive skills (Heckman & Kautz, 2012).

These types of ideas are continuing to gain prominence in the field of economics, building on Heckman’s and others’ work. For example, a recent study finds that soft skills, particularly interpersonal or social skills, have become increasingly important predictors of labor market outcomes such as employment and wages (Deming, 2017). Cognitive skills remain important—they are necessary but not sufficient to be successful in many occupations that also require social skills. Deming hypothesizes and finds empirical support for a mechanism by which social skills determine people’s ability to work effectively in teams, which involves “trading” work activities based on one’s comparative advantages in skills. In a dynamic, flexible environment, this requires effective interpersonal communication and understanding among team members.

Despite these many reasons for enthusiasm for SEL programs, the experts interviewed for this article agreed that changes in practice and policy have been modest. This view is consistent with the limited data available on the national penetration of SEL programs. An estimated 25,000 schools use the Positive Behavior Interventions and Supports (PBIS), a general framework to address behavior and school climate, according to the program’s website. But this framework does not necessarily imply a thorough implementation, nor any kind of comprehensive curriculum, and 25,000 is still a modest fraction of the more than 100,000 elementary and secondary schools in the U.S. For specific SEL programs with the strongest evidence of effectiveness—such as PATHS and Positive Action—the national penetration is much lower, at less than 3%, as noted.

This situation reflects a number of challenging barriers to widespread implementation. Perhaps the biggest barrier is simply that educators, in an era of school accountability and standardized testing, are reluctant to dedicate the time in school curricula that is necessary to implement comprehensive, structured programs such as PATHS and Positive Action. The evidence generally suggests that these types of programs are less impactful when they are not fully implemented, as would be expected (Durlak et al., 2011).

Jones, Bailey, Brush, and Kahn (2017) propose a “kernel” approach as a solution to the limited space in school curricula. They have looked for common elements, or “common denominators,” in programs that have positive outcomes. They hypothesize that these common elements are likely to be the active ingredients, and examine how to implement them in as light and flexible ways as possible. They note that this approach is well received by practitioners in schools, who appreciate the agency and flexibility. This lighter approach also yields a variety of ways to integrate into the full school context rather than just classrooms and formal curricula.

Another implementation challenge is the fact that some of the strongest programs, such as PATHS, insist on intensive in-person training for teachers and school professionals who deliver the program. This attention to quality and fidelity of implementation maximizes the chances of positive outcomes, but requires considerable investments of staff time. Again, the reluctance of schools to devote substantial time and resources becomes a barrier.

Overall, SEL programs represent a promising investment with exciting opportunities for growth. There is a solid base of evidence that some programs have short-term benefits. Those short-term benefits alone may warrant the modest costs associated with implementing programs. For this investment to reach a wider scale in the U.S. and beyond, it is important to understand more fully the longer-term benefits, the mechanisms of action, and the most efficient training and implementation strategies. The recent attention to school safety may help sustain interest in this area, as policymakers and other stakeholders increasingly recognize the important role that schools play in young people’s social and emotional development.

Policy Implications for Investments in Child Mental Health

In light of the evidence and examples discussed in this article, there are several implications for public policy regarding investing in children’s mental health, despite the many gaps in knowledge. First, there are several programs and services with strong evidence in favor of their effectiveness and cost-effectiveness. Funders can make these investments with confidence, assuming that the programs and services are implemented properly. Second, there is an even larger number of programs with some promising evidence but high levels of uncertainty. This set of programs warrants continued investment alongside careful evaluation; in some cases, the results will increase confidence in the investments, and in other cases the results will suggest the need for modifications or discontinuation.

Third, these best investments, and potential best investments, span a wide range of approaches in terms of developmental and social-ecological levels. This conclusion points to an opportunity to address children’s mental health through a wide variety of contexts, rather than focusing exclusively on one or two areas. Although it is tempting to try to identify a silver bullet intervention, children’s mental health can be improved throughout childhood and adolescence, and through contexts including families, schools, and more.

Fourth, even programs with the strongest evidence are only reaching a small portion of children and families who could benefit, despite very favorable benefit-cost ratios in many cases. Fifth and relatedly, the limited penetration of best investments can be attributed to a number of thorny implementation challenges; these include policy factors such as misalignment of financial incentives and lack of coordination across sectors, organizational factors such as turnover in leadership, and service provider factors such as lack of adequate training and professional development. At this stage there are few obvious answers to these challenges. As a starting point, however, one can look to pockets of success, such as recent investments in home visiting and SEL programs, and learn from those experiences.

What are the next steps for research, practice, and policy? There are many remaining uncertainties, as discussed throughout this article; therefore, any recommendations are preliminary at this stage, and must be reassessed and elaborated upon as researchers, policymakers, and practitioners build on this agenda. A first recommendation is for policymakers and other community leaders to invest more heavily in the small number of investments with the strongest evidence. These investments must include not simply financial and human resources but also strategic, coordinated efforts to overcome the main implementation challenges. Next, policymakers and community leaders should continue to experiment with and resolve uncertainties for promising and uncertain investments. For learning to occur, the experimentation must be accompanied by rigorous evaluations whenever possible. Next, scholarly discussions of investing in children’s mental health need to bring together multidisciplinary perspectives, including economics, social ecology, child development, and implementation science. Similarly, policy discussions must bridge across the interests and perspectives of the many sectors and stakeholders who support the healthy development of children. The hope is that this article will serve as a stimulus for these discussions.

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