the drug, alcohol and suicide crises and the need for a national resilience strategy

200 Pages·2017·9.01 MB·English

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Acknowledgements
Trust for America’s Health is a non-profit, non-partisan organization Data analysis and projections were provided by Berkeley
dedicated to saving lives by protecting the health of every community Research Group (BRG), a global strategic advisory and expert
and working to make disease prevention a national priority. consulting firm that provides independent advice, data analytics,
authoritative studies, expert testimony, investigations, and
Founded in late 2016 with a $100 million endowment from
regulatory and dispute consulting to Fortune 500 corporations,
Providence St. Joseph Health, Well Being Trust is a national
financial institutions, government agencies, major law firms, and
foundation dedicated to advancing mental, social and spiritual
regulatory bodies around the world. www.thinkbrg.com.
health. Created to include participation from organizations across
sectors and perspectives, Well Being Trust is committed to This report is supported by grants from the Robert Wood Johnson
innovating and addressing the most critical mental health challenges Foundation and WBT. TFAH thanks the foundations for their
facing America, and transforming individual and community generous support. The opinions in this report are those of the
wellness. www.wellbeingtrust.org. Twitter: @WellBeingTrust authors and do not necessarily reflect the views of the supporters.
TFAH BOARD OF DIRECTORS
Gail C. Christopher, DN Theodore Spencer Octavio N. Martinez, Jr., MD, MPH, Umair Shah, MD, MPH
President of the Board, TFAH Secretary of the Board, TFAH MBA, FAPA Executive Director and Local
President and Founder Senior Advocate, Climate Center Executive Director Health Authority
Ntianu Center for Healing Natural Resources Defense Council Hogg Foundation for Mental Health Harris County Public Health
and Nature at the University of Texas at Austin
David Fleming, MD Vince Ventimiglia, JD
Cynthia M. Harris, PhD, DABT Vice President C. Kent McGuire, PhD Chairman
Vice President of the Board, TFAH PATH President and CEO Vice Chairman of Leavitt Partners
Director and Professor Southern Education Foundation Board of Directors
Stephanie Mayfield Gibson, MD
Institute of Public Health, Florida Leavitt Partners Board of Managers
Senior Physician Adviser and Karen Remley, MD, MBA, MPH,
A&M University
Population Health Consultant FAAP
Robert T. Harris, MD Private Contractor CEO/Executive Vice President
Treasurer of the Board, TFAH American Academy of Pediatrics
David Lakey, MD
Medical Director
Chief Medical Officer and Associate Eduardo Sanchez, MD, MPH
North Carolina Medicaid Support
Vice Chancellor for Population Health Chief Medical Officer for Prevention
Services
The University of Texas System American Heart Association
CSC, Inc.
REPORT AUTHORS CONTRIBUTORS PEER REVIEWERS
Laura M. Segal, MA Benjamin F. Miller, Psy.D. TFAH thanks the following individuals and organizations for their
Vice President of Public Affairs Chief Policy Officer time, expertise and insights in the reviewing all or portions of the
Trust for America’s Health Well Being Trust report. The opinions in the report do not necessarily represent the
Anne De Biasi, MHA Tyler Norris, MDiv views of these individuals or their organizations.
Director of Policy Development Chief Executive
Jay C. Butler, MD Corey Davis, JD, MSPH
Trust for America’s Health Well Being Trust
Chief Medical Officer Deputy Director, Southeastern Region
Jennifer L. Mueller, JD Genny Olson, MPH Alaska Department of Health & Network for Public Health Law
Consultant Policy Development Associate Social Services
Gary Mendell
Trust for America’s Health
Kendra May, MPH The Honorable Mary Bono Founder & CEO
Consultant Principal Shatterproof
Faegre Baker Daniels Consulting
Molly Warren, SM Former Member of Congress Vivek H. Murthy, MD, MBA
Health Policy Research Manager Former Surgeon General of the
Trust for America’s Health Sean Clarkin United States
EVP, Senior Program Officer
Corinne Peek-Asa, PhD
Partnership for Drug-Free Kids
Associate Dean for Research and
Nathaniel Z. Counts, JD Director of the Injury Prevention
Cover photos: Phil Lowe/Shutterstock.com and Shutterstock Senior Policy Director Research Center
Mental Health America College of Public Health,
University of Iowa
2 TFAH • WBT • PaininTheNation.org
Pain in the T
Table of Contents A
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Nation:
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INTRODUCTION ......................4 3. Expand and Improve the Mental Health
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and Behavioral Health Workforce.
Financial incentives, expanding types of Public Health F
SECTION 1. PROJECTIONS: Possible Futures of
providers, training and evidence-based C
Drug, Alcohol and Suicide Deaths ........15
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guidance, knowledge sharing........95
1. Drug-Related, Alcohol-Related or Suicide Report N
4. Prioritize Needs in Underserved
Deaths: 1999, 2016, 2025 Projected T
Areas – Including Rural and Low-
Scenarios........................15 E
Income Communities. Bolster federal N
Projected Annual Growth Rate Scenarios for investment, use leverage as public payer, series T
National Deaths ...................16
maximize coverage enrollment, expand S
State-by-State Drug, Alcohol and Suicide workforce and telehealth, incentivize
Deaths..........................20 behavioral health careers, community
programs to fill gaps ............ 96
SECTION 2. Healthcare Costs Associated With 5. C onnect Healthcare and Behavioral Health
Drug, Alcohol and Suicide Diagnoses..... .26 Services with Social Service Supports.
1. Drug-Alcohol-Suicide Average vs. Overall Two-generation support; prenatal and
Healthcare Spending................26 preconception care; crisis services; trauma-
informed services and systems....... 98
Drug-Alcohol-Suicide Diagnosis Prevalence ..26
6. Reduce Stigma. Non-discriminatory
State-by-State Costs ................27
evaluations procedures; stigma-reduction
messaging and communications
SECTION 3. Review Of Key Policies For
programs ....................103
Improving Well-Being .................28
7. Early Identification of Issues and
A: Reducing Drug and Alcohol Misuse and
Connections to Services and Care. Early
Suicide .........................29
childhood screenings; family risk factor
1. P reventing and Reducing Opioid and Other screening; and school-based and tween/
Drug Misuse. Community-based strategies; teen screenings ................104
surveillance; responsible prescribing
— provider education and Prescription C: Prioritizing Prevention – Promoting
Drug Monitoring Programs; safe storage, Healthier Communities and Raising
disposal and Take Back programs; tamper- a Mentally and Physically Healthier
resistant formulations; stopping illicit Generation of Kids ................112
supply; reducing harm and preventing 1. Supporting Local Multi-Sector
overdoses — naloxone, Good Samaritan Partnerships. Expert and technical
laws, diversion, sterile syringes ......30 assistance....................113
2. R educing Excessive Alcohol Consumption. 2. Impact of the Opioid Epidemic on
Pricing policies; access and availability; Child Welfare – and the Need for Multi-
limiting underage and intoxicated customer Generational Care...............119
sales; reducing underage drinking; reducing
3. E arly Childhood Well-being Policies. Home
drinking and driving ............... 60
visiting programs; evidence-based parent
3. Effective Approaches for Preventing education/support initiatives; child care
Suicides. Statewide prevention plans; and childhood education; social-emotional
risk and treatment training for medical learning programs; continuum of services
professionals; mental health parity and early care to elementary school ..... 123
access; limiting “hotspots” and lethal
4. S chool-Aged Children, Tweens and Teens
means; expanding National Violent Death
Policies. Prioritize a healthy, positive school
Reporting System; responsible media
climate; evidence-based social-emotional
reporting ......................69
learning, life and coping skills programs;
sustained evidence-based substance
B: Improving Behavioral Healthcare – to
misuse prevention; anti-bullying programs;
Support “Whole Health”.............80
expand personnel, professional development
1. Modernize Behavioral Health Services.
opportunities; school health services;
Improve health insurance coverage
school-based suicide prevention plans ..129
and affordability; delivery and payment
models; effective treatment and recovery 5. Family Opportunities – Addressing Core N
practices; models and practices for Needs and Promoting Stability. Income O
assistance; housing assistance and
behavioral healthcare integration .....86 V
transportation; nutrition assistance; E
2. M odernize Substance Use Disorder
health insurance, creating economic M
Treatment. Expand the workforce; provider
opportunity....................141 B
guidelines and insurance policies and
E
provider practices.................90
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SECTION 4. Recommendations for Building a

National Resilience Strategy...........148 2
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INTRODUCTION
I Pain in the
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Introduction
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O Nation:
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C Public Health The United States is facing a new set of epidemics — more than
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I 1 million Americans have died in the past decade from drug
I
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Report
N overdoses, alcohol and suicides (2006 to 2015).1 Life expectancy
in the country decreased last year for the first time in two
series
decades — and these three public health crises have been major
contributing factors to this shift.
In 2015 alone, 127,500 Americans died policies, practices and programs to take
from drug- or alcohol-induced causes or a more comprehensive approach to
suicide.2 That equates to 350 deaths per counter these crises.
day, 14 per hour and one person dying
If more action is not taken, these trends
every four minutes.
will become significantly worse.
These trends are a wake-up call that
In fact, a new analysis conducted by the
there is a serious well-being crisis in this
Berkeley Research Group (BRG) for this
country. In stark terms, they are signals
report found that if the current rise in
of serious underlying concerns facing too
drug, alcohol and suicide death trends
many Americans — about pain, despair,
continue — over the next decade, these
disconnection and lack of opportunity —
three epidemics would be expected to
and the urgent need to address them.
result in more than 1.6 million deaths
In this report, the Trust for America’s (by 2025). This would represent a 60
Health (TFAH) and Well Being Trust percent increase over the current level.
(WBT) call for the need to develop a
There could be a rise in deaths from
national strategy to improve resilience
127,500 (39.7 per 100,000 in 2015) to
in the United States. The report
192,000 (55.9 per 100,000 in 2025)
examines current trends and evidence-
nationally.
based and expert-recommended
U.S. Drug, Alcohol, or Suicide-Related Deaths
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For a growing majority of states, the would result in 2 million deaths over the
outlook posed by these threats is even next 10 years. (Note: final data for 2016
more concerning. rates will be revised and confirmed in late
2017 or early 2018).
l A s of 2015, five states had death rates
of 60 per 100,000 or higher, with New The rapid rise of these epidemics over
Mexico having the highest rate of 77.4 the past 15 years constitute three of
per 100,000. Alaska, New Hampshire, the most serious public health crises
West Virginia and Wyoming were of this century. The life-and-death
between 60 and 70 per 100,000. consequences of drug and alcohol misuse
and suicide have reached urgent levels
l By 2025, if current trajectories
in many communities. In addition, wide-
continue, 26 states are projected to
scale substance misuse and insufficient
reach 60 deaths or more per 100,000,
attention to mental health disorders have
with two states possibly reaching 100
broad impact. The added recent dramatic
deaths per 100,000 (New Mexico and
increase of illicit opioids — heroin and its
West Virginia).
blending with the more potent fentanyl
The latest reports from the Centers for and even more potent carfentanil — have
Disease Control and Prevention (CDC) made the immediate situation even more
using provisional data for trends in dire and complicated.
2016 have found that drug overdoses
While the crises have received much
have grown at an even faster pace than
attention — this report finds the
expected during the first nine months of
actions that have been taken to date are
2016,3 which, based on this analysis, would
severely inadequate.
put the country on a worst-case track and
TFAH • WBT • PaininTheNation.org 5
THE CURRENT CRISIS
l Drug-related deaths have tripled since all alcohol-attributable deaths — l While overall death rates are higher
2000 — and were responsible for more including alcohol-related motor vehicle, among Blacks and other people of
than 52,400 deaths in 2015.4, 5 More violence and other fatalities — total color, the Surgeon General noted
than 33,000 of these were from opioids, 88,000 a year.10, 11 that substance misuse and suicide
mainly prescription opioids (pain are leading drivers of lowered U.S.
• 15.7 million Americans (5.9 percent)
reducers), heroin and fentanyl. life expectancy for the first time
have an alcohol use disorder.
in decades, with an unprecedented
• 7.7 million Americans (2.9 percent)
• In addition, millions of Americans
increase in mortality among middle-aged
have a drug use disorder.
consume alcohol “excessively”
Whites in the past 15 years.16
• There was a 72.2 percent increase in (binge or heavy drinking) putting
• Life expectancy rates declined 20
fentanyl-related deaths (fentanyl is a them at risk for injuries or other
percent among middle-class Whites
synthetic drug that is 50 to 100 times harms. Nine out of 10 excessive
with less than a college education
more potent than heroin, and is often drinkers do not have an alcohol use
during this time period, with deaths
“cut” with heroin); and 20 percent rise disorder, but excessive drinking is a
from drug overdoses, alcohol
in heroin-related deaths between 2014 risk factor for alcohol use disorders
poisoning, liver disease and suicide
and 2015. In 2016, provisional data — as well as for suicide and other
all tripling among this cohort. These
show fentanyl became the leading forms of violence — and one in
trends have not been seen within other
cause of drug overdose — at 21,000 five individuals who die from opioid
racial and ethnic groups.17, 18
overdose deaths, which would be overdoses also have alcohol in their
double the rate in 2015.6 system at time of death. • O verall, however, death rates among
Blacks remain significantly higher than
• In 2015, the amount of opioids
l S uicides increased by 28 percent from
for Whites. For instance, among middle-
prescribed could medicate every
2000 to 2015, accounting for more
aged individuals (ages 25 to 64 years
American around the clock for
than 44,000 deaths a year. Although
old), death rates among Blacks are 67
three weeks.7 Opioids are currently
suicide rates are higher among men,
percent higher than Whites in urban
prescribed at rates three times higher
the highest increases have been
areas, 30 percent higher in suburban
than they were compared to 1999
among middle-aged women (63 percent
areas, 46 percent higher in small/
(prescribing rates peaked at more than
increase) and girls ages 10 to 14 (200
medium metro areas and 39 percent
four times that level in 2010).8
percent increase).12, 13
higher in rural areas. These differences
l Alcohol-induced deaths have reached • Alcohol use is involved in around 23 have implications for examining a range
a 35-year high — growing by 37 percent of suicides and around 40
of root causes that impact premature
percent from 2000 to 2014 — with percent of suicide attempts, and 16
death and behavioral health, such as
33,200 Americans dying from liver percent of suicides are from poisoning
poverty and adverse circumstances,
diseases, alcohol poisoning and other (including drug overdoses).14, 15
which can impact life expectancy.19, 20
diseases as of 2015.9 The rate for
ECONOMIC COSTS
A new BRG analysis conducted for this report also found that Around 3.8 percent of the population had at least one of the
healthcare spending for individuals who have a diagnosis diagnoses in 2014. Combined, these patients had annual
related to drugs, alcohol or individuals at risk for suicide healthcare costs of $249 billion — roughly 9.5 percent of total
are 2.5 times higher than the average American adult, at health expenditures in the United States.
$20,113 per patient per year.
6 TFAH • WBT • PaininTheNation.org
A National Resilience Strategy
This report calls for the creation of a National Resilience
Strategy — a comprehensive approach to improve the lives
of Americans — and address the factors that contribute to
substance misuse, suicide and other related harms.
The country has long struggled with the country views and manages mental
effective approaches to promoting positive health, pain and despair — and without
mental and behavioral health — and to better strategies that focus on preventing
effectively manage all forms of pain.21 problems and providing effective support,
services and treatment, the trends are
The confluence of “despair deaths” are
likely to be perpetuated and get worse.
directly related to pervasive issues with how
l M ental Health and Substance Use health workers and 77 percent report around 100 million experience
Disorders: In 2016, 44.7 million American unmet behavioral health needs.27 chronic pain; millions experience
adults experienced a mental illness, acute pain from injury, disease or
• More than 40 percent of adults with
20.1 million experienced a substance medical procedures; and millions
a substance use disorder in the
use disorder and 8.2 million experienced experience mental, emotional and other
past year also experienced mental
both — and these numbers are likely to be psychological forms of pain.31
illness compared with 16 percent
underestimated due to issues of stigma.22
among the rest of the population (2.5 • I n the 1990’s, there were
• A s many as one in five children and times likelihood); and 18.5 percent developments in the availability of
teens have had a serious debilitating of adults with a mental illness also prescription opioids — and they
mental disorder, with half of the mental had a substance use disorder in the were rapidly adopted and used as
health conditions starting by the age past year compared with 5.4 percent a major pain management strategy.
of 14 — and more than 25 percent of among the rest of the population Prescription opioids have been
teens are impacted by at least mild (three times likelihood).28 important for helping many patients
symptoms of depression.23, 24, 25 manage pain when used effectively
• Medicaid accounts for 25 percent of
and appropriately under provider
• Only around one in 10 individuals all mental health and 21 percent of
supervision. However, their widespread
(10.6 percent) who needed substance use disorder spending.29
availability and use has contributed to
substance use treatment received the Nearly half of Medicaid spending
misuse, increased addiction and the
recommended treatment at a specialty is on care for the 20 percent of
“masking” of the need to develop other
facility in 2016. Comparatively, four beneficiaries who have a behavioral
effective and integrated approaches
in nine adults with any mental illness health diagnosis.30
to address pain — and the need to
received mental health services.26
l Chronic Pain: Millions of Americans address the factors that contribute to
• Fifty-five percent of U.S. counties do suffer from pain — the National different types of pain and suffering.
not have any practicing behavioral Academy of Medicine (NAM) estimates
TFAH • WBT • PaininTheNation.org 7
Children whose parents misuse
l Adverse Childhood Experiences: Two- below the poverty line, and 45 percent
alcohol and other drugs are three thirds of Americans report having are in low-income families.42 Children
experienced an adverse childhood who grow up in persistent poverty or
times more likely to be abused
experience (ACE) while growing up — low-income families are more likely to
and more than four times more across all socio-economic levels. Nearly remain poor as adults, and have lower
40 percent experienced two or more educational attainment and employment
likely to be neglected
ACEs, and 22 percent experience three — and have more adverse mental and
or more ACEs.32, 33, 34, 35, 36 physical health status.43
• C hildren who grow up in an environment l Maltreatment of Children: More than
where a member of the family has 680,000 children experience severe
a mental illness or alcohol or drug forms of maltreatment annually (79
use disorder can have lifelong health percent from neglect and 18 percent
consequences — with the impact being from physical abuse), one-third of
strongest for infants and toddlers — these are children under the age of
and is considered an ACE.37 four.44 Around 400,000 are in out-of-
home foster care at any time.45 Of
• Children whose parents misuse
these children, more than 60 percent
alcohol and other drugs are three
of infants and 40 percent of older
times more likely to be abused and
children are from families with active
more than four times more likely to
alcohol or drug misuse.46
be neglected than children from non-
substance misusing families.38 This • T he opioid epidemic is intensifying the
in turn increases the risk that they strain on child welfare systems. The
will develop anxiety disorders, severe number of children in foster care across
personality disorders and misuse the country increased by 8 percent
alcohol and drugs themselves.39, 40 between 2012 and 2015.47, 48 Some
states with particularly high increases
• P arents who misuse alcohol or
around this timeframe include Florida
other drugs are more likely to be
(24 percent increase), Georgia (74.5
experiencing multiple sources of
percent increase), Indiana (37 percent
stress themselves, including low socio-
increase), Kentucky (33 percent
economic status, lack of social support
increase) and Minnesota (33 percent
and resources, financial or emotional
increase).49, 50 A number of states have
distress, mental health problems such
issued emergency pleas for additional
as depression, or have experienced
foster parents, and there are increased
abuse when they were growing up.41
reports of grandparents and other
l Consequences of Persistent and family members caring for children
Prolonged Stress: One in five babies whose parents are struggling with
and toddlers (around 23 percent) live opioid use disorders.
8 TFAH • WBT • PaininTheNation.org
The opioid crisis has gained urgent
national attention. It has led to
Presidential commissions, numerous
states declaring states of emergency
and communities around the country
struggling with managing the life-and-
death issues of first responders, hospital
emergency departments confronting
high rates of overdoses and major gaps
in the ability to provide treatment for
individuals with opioid use disorders.
States and communities are also facing
the consequences of the crisis on
children and families — with significant
increases in the number of babies
born with neonatal opioid withdrawal
syndrome, children being placed in
foster care and other family members
being called upon to care for children
of parents struggling with addiction.
Many of the strategies to address the
opioid epidemic have focused on trying to
limit the supply of prescription and illicit
forms of opioids along with measures to poor working conditions and eroded It presents a scan of the evidence
respond to overdoses and attempts to try social capital in depressed communities, and summary of the fragmented
to address major gaps in the country’s accompanied by hopelessness and and often inadequate national support
substance use disorder treatment despair.” 51, 52, 53, 54, 55, 56 In addition, constellation of existing policies
capabilities, rapidly attempting to expand causation goes in both directions — and programs to address these pressing
and modernize the types of treatment substance misuse and untreated mental issues. One thing is clear: there is an
available to those in need. health issues can adversely impact immediate need to develop an actionable
health, academic and career attainment, national response to alcohol and drug
However, these efforts are inherently
relationships with family and friends and misuses and death by suicide. Not only
insufficient — and will not succeed
the ability to be a connected part of a are these urgent health crises across this
unless there are corresponding efforts
community. country, they are indicators of the need
to address the broader issues that
to go deeper and to look at underlying
contribute to adverse well-being and A National Resilience Strategy is needed
causes and opportunities to create an
underlying pain. The rise of multiple to create a more comprehensive, focused
integrated approach to well-being for
despair deaths and related trends show and effective approach that prioritizes
all people, and especially for those who
there is a more significant dynamic that putting prevention first, promoting
are at a high risk for experiencing these
needs to be addressed. positive mental health, and that develops
challenges. The findings of this report
systems of support to identify issues
While the availability of drugs and alcohol serve as a call to action from leaders
early and ensures Americans receive the
does contribute to higher use, there are across all sectors and regions/states to
support and care they need to thrive.
many other factors that contribute to come together to develop a thoughtful
substance misuse and risk for suicide — This report offers a critical look at both and inclusive framework for systemic
including family and social relationships, past and projected impacts and outcomes change that measurably improves
social-emotional development, ACEs of opioid and alcohol misuse, including outcomes tied to well-being and health.
and “lack of economic opportunity, overdoses, and death by suicides.
TFAH • WBT • PaininTheNation.org 9
Tweens and teens are coming of age with new and different substance misuse risks of prescription
opioids, heroin and heroin mixed with other drugs. Family and community influences also increase the
risk for a child’s future misuse of alcohol and for both suicidal thoughts and suicide.
There must be a paradigm shift in the Experts have identified a broad range of better well-being. Key factors
response to these challenges — with top of policies and programs that can include: nurturing, stable caretakers
priorities that include: achieve results for reducing substance and relationships; good nutrition
misuse and suicide, and promoting and physical activity; positive
l Increasing Access to Policy and
resilience by reducing risk factors and learning experiences; a safe home,
Programmatic Advice and Support
supporting positive protective factors neighborhood and environment; and
– Establishing Expert Networks.
(such as stable, secure families, homes high-quality, preventive healthcare.
The opioid crisis is a stark and clear
and communities). These programs, Early intervention to prevent issues
demonstration of the intergenerational
however, are often ad hoc — and are not can help avoid a “cascade of risk,”
impact of behavioral health issues —
provided at scale or coordinated to work including the multi-generational
and the urgent need to address the
together to achieve maximum results impact of adverse experiences.57
effect on children. Solutions must
for families. There needs to be new Improved systems are needed to
focus on providing support for the
models and infrastructure that support coordinate the services and supports
individual with a substance use disorder
better alignment, integration and case available to children and families at
— but also for the children, parents
management of services and supports risk — helping to identify problems
and families impacted. The epidemic
for families — across healthcare, early and ensure families receive
is creating a new compounded and
behavioral health services and other necessary care. Some impactful
complicated generation of ACEs —
social services. New mechanisms must early childhood programs include:
which research shows have a long-term
also be supported to help lead, integrate high-quality home visiting programs;
effect on children’s lives. Tweens and
and manage community-based efforts evidence-based parent education
teens are coming of age with new and
to address the opioid, alcohol and and support; high-quality child care
different substance misuse risks of
suicide crises — and improve well-being and early education; and services
prescription opioids, heroin and heroin
— to help ensure that the top needs that support the transition from early
mixed with other drugs. Family and
and problems are being addressed in childhood programs to elementary
community influences also increase
ways that effectively use the expertise school. It is also important to provide
the risk for a child’s future misuse of
and resources available across local support for families to support stability
alcohol and for both suicidal thoughts
institutions and businesses to support and resilience, including financial,
and suicide. Systems and supports
these efforts. In addition, it is important food, housing and transportation
must be aligned and maximized to
to bring the leaders and resources of assistance — and quality healthcare.
support family needs — to provide
a community together to support an
support for prevention and treatment • Rebooting School-Community Efforts
improved sense of community, social
services for mental health and to Support Tweens and Teens. There
connectedness and commitment to
substance use disorders, supporting in- is significant evidence for approaches
work together to promote economic
home parenting skills and ways to keep to support better well-being during
opportunity initiatives.
children with parents or other family the tween and teen years — at a
members when possible. • Focusing on Early Childhood. time when many individuals face
Investing in early childhood many transitions, including changes
l Putting Prevention First. A multi-
policies and programs will have in schools and relationships when
generational system must include
the biggest impact for reducing mental health concerns become
a coordinated, effective system for
risks and supporting a lifetime evident and risk for substance
supporting children and families.
10 TFAH • WBT • PaininTheNation.org