7

The Evidence Base on Policies

As discussed in Chapter 1, the national infrastructure to prevent mental, emotional, and behavioral (MEB) disorders requires multilevel approaches that include adopting and expanding the set of evidence-based programs (see Chapter 2) and policies (Akers et al., 2022; Alegría et al., 2022). This chapter responds to study sponsors’ request that the committee consider policy as an intervention. Policy is critical infrastructure because it can function as universal prevention—with broad reach to large portions of the population. Policies can positively or negatively affect population MEB health and therefore represent critical infrastructure both indirectly and directly. First, policies indirectly influence the upstream factors that promote MEB well-being, such as economic stability, health care and education quality and accessibility, as well as neighborhood and social context. Second, policies can directly affect MEB health by promoting protective factors and reducing risk factors. Ultimately, all types of policies can shape individual behavior—for example, policies that discourage alcohol use through taxation and other strategies lead to lower rates of excessive alcohol use (CDC, 2024b), and policies that expanded Medicaid and improved health care access led to reduced symptoms of depression (Baicker et al., 2013). Policies are necessary to promote MEB health and well-being, but they need to be enforced and implemented effectively. Policies also can be part of multilevel interventions that incorporate programs (Moore et al., 2024).

This chapter briefly highlights U.S. social, economic, and environmental policies that have been shown to have positive effects on MEB health in National Academies of Sciences, Engineering, and Medicine (National Academies) reports (see simple chapter “map” in Table 7-1). For example,

TABLE 7-1 A Map to the Chapter Contents

Fostering Healthy Mental, Emotional, and Behavioral Development in Children and Youth: A National Agenda stated that “policies influence the distribution of wealth, employment and the health care, education, welfare, and juvenile justice system—all of which have implications for MEB development and health” (NASEM, 2019a, p. 188). In addition to discussing indirect effects on MEB health, the report also briefly examined policies that are known to directly influence MEB health outcomes, many of which have been evaluated in previous National Academies reports. The list includes health care access and affordability; Maternal, Infant, and Early Childhood Home Visiting; Mental Health Parity Act; Special Supplemental Nutrition for Women Infants and Children (WIC), Supplemental Nutrition Assistance Program (SNAP), and the National School Lunch Program (NSLP).

The 2019 report also reviewed the effects on MEB outcomes of minimum wage laws, paid family leave, Earned Income Tax Credit (EITC), child care subsidies, and Temporary Assistance for Needy Families (TANF). The report further discussed policies that impact access to alcohol and tobacco, regulate lead exposure, require seatbelts and bicycle helmets, and promote firearm and community safety, as well as education policies including Every Student Succeeds Act (ESSA), Individuals with Disabilities Education Act (IDEA), and state policies on socioemotional learning. This chapter briefly highlights many of the economic, social, and environmental policies examined in the 2019 report. It also discusses in much greater detail two topics very briefly addressed in the 2019 report (and not substantively explored in other recent National Academies work) and for which the evidence base has grown considerably in recent years: mass incarceration and firearm violence. The committee points to their role as important indirect and direct factors in MEB health, especially for low-income and minoritized communities, veterans, and children. Firearm injuries are the leading cause of death for young people, involved in 30 percent of suicides in youth, and also a major cause of psychiatric disorders in youth who are survivors of firearm

violence (McKie et al., 2024; Song et al., 2023). Incarceration has clear and explicit links to poor MEB outcomes, pointing to key opportunities for prevention (Mendel, 2023b). A final section briefly discusses two areas of evolving policy at the national and state levels, where additional research is needed: the effects of social media on MEB health and well-being, and the effects on LGBTQ+ youth of policies that limit what they can do and the care they can receive.

ECONOMIC POLICIES AND MEB HEALTH

Income Support, Earnings Replacement, and Employment Support

Income support policies, such as the EITC and Child Tax Credit, have shown positive effects on MEB health. Both policies function to alleviate poverty, which places stress on families. Further, evidence shows that reducing poverty can improve educational outcomes, reduce interactions with the criminal legal system, and improve access to health care (NASEM, 2017; NASEM, 2019d). According to the Reducing Intergenerational Poverty report, “interventions such as the EITC that promote employment and increase income improve children’s long-run outcomes; interventions that promote employment in the absence of increased income do not appear to improve child outcomes; and evidence on whether income supplementation alone improves long-term child outcomes is inconclusive, with some studies showing positive effects and others showing no improvement” (NASEM, 2024b, pp. 157–58).

The EITC has been consistently shown to increase employment for single parents and, in 2018, lifted about 5.6 million people above the poverty line, including nearly 3 million children, based on the Supplemental Poverty Measure (SPM) (CBPP, 2023). It has been associated with improvements in infant and maternal health and educational attainment (see review by Hoynes and colleagues [2015]). The EITC is associated with fewer depressive symptoms and reduction in deaths by suicide, and recent research on the effects of the temporary expansion of the Child Tax Credit (from $2,000 to $3,600 and covering a larger subset of low-income families) showed positive effects on the mental health (MH) and well-being of adults in affected families (Batra et al., 2023; Boyd-Swan et al., 2015; Dow et al., 2020).

Employment support includes paid leave and child care subsidies. Paid maternity leave is associated with improved maternal MH (Heshmati et al., 2023). Mothers who received some paid leave had lower levels of depressive symptoms than those who did not. Longer leave has also been associated with lower levels of depressive symptoms (Heshmati et al., 2023). A study found increases in exercise and improved stress management among women who

took paid parental leave compared to those who took no or unpaid leave (Jou et al., 2018). Paid family leave is also associated with improved MEB health. A 2021 study found that levels of emotional distress statistically decreased among adults with paid family leave policies (Irish et al., 2021). Direct cash transfers have shown positive (though sometimes temporary) effects—one recent randomized trial showed reductions in emergency room visits for MH disorders, and another showed modest and time-limited improvements in subjective well-being (Agarwal et al., 2024; McKay et al., 2023).

Research has shown that the expanded Child Tax Credit was associated with a reduction in anxiety symptoms for recipients (Batra et al., 2023; Cha et al., 2023; Nam and Kwon, 2024), with some noting significantly more pronounced effects for Black and Hispanic adults with children (Batra et al., 2023; Cha et al., 2023) and women (Cha et al., 2023) compared with non-Hispanic White adults (Batra et al., 2023; Cha et al., 2023). Batra and colleagues (2023) also found reduced depressive symptoms among low-income adults.

Social Security Income (SSI) benefits have also been shown to reduce depressive symptoms among older adults. Golberstein (2015) exploited the “notch” in SSI that led certain cohorts of beneficiaries to receive payments doubly indexed for inflation. These increases in payments were especially large for women, given their lower overall income, and the study reports that $1,000 of SSI led to an improvement of 0.541 points (27 percent) on the Center for Epidemiologic Studies Depression Scale, CES-D (Golberstein, 2015).

In-Kind Support: Housing, Health Insurance, and Nutrition

Housing

Housing is a basic human need with direct linkage to MEB health. Research comparing families randomly assigned to a permanent housing subsidy, community-based rapid rehousing, project-based transitional housing, or “usual care” (any services that are not an immediate referral to other interventions) over 3 years found the families who received the permanent subsidy experienced reduced psychological distress, signs of substance and alcohol use issues, and intimate partner violence incidence (by half) compared with families receiving usual care (Gubits et al., 2015). In children, research shows reduced behavioral challenges and more prosocial behavior when provided improved housing conditions (Gubits et al., 2015; Sard et al., 2018). In addition, the quality of neighborhoods matters: the Moving to Opportunity experiment found that living in a low-poverty neighborhood had positive impacts on adults’ mental and physical health, including decreased rates of depression, and on the MH of female children (Chetty

et al., 2016). As the frequency and severity of natural disasters increases due to climate change, the consequences, including destruction of housing and displacement, pose additional risks for MEB disorders (SAMHSA, 2024a,b).

Health Insurance

The ability to pay for health care is included in the Global Social Development Innovation’s definition of economic security (GSDI, 2021). Expanding Medicaid and the State Children’s Health Insurance Program in 1997–2002 was associated with improved MH for teenagers, with boys specifically experiencing a significant increase in the likelihood of the highest level of MH. It also created spillover effects for parents, who experienced slightly better MH (Hamersma and Ye, 2021). Expanding Medicaid in Oregon via lottery also improved adult MH; some effects could be due to reduced financial precarity, as medical bills are a leading cause of household debt (Baicker et al., 2013; Kluender et al., 2021; Maas, 2016).

Nutrition

Food insecurity is a well-documented source of stress, undermining the psychological well-being of adults and children (Pourmotabbed et al., 2020; Wolfson et al., 2021). A patchwork of federal programs provides food assistance to specific groups considered particularly vulnerable: WIC, NSLP, and SNAP. NSLP was expanded during COVID-19 to include all students—though federal support stopped in June 2022, several states have decided to continue free school meals because they are destigmatizing. Evidence has shown free school meals improved psychosocial functioning, anxiety, and depression symptoms in children (Murphy et al., 1998). WIC recipients who are more food insecure have been shown to have more depressive symptoms (Herman et al., 2024). Moreover, preschool children whose mothers participated in WIC were less likely to be diagnosed with attention-deficit/hyperactivity disorder (Carlson and Neuberger, 2021). Research suggests that states that removed asset tests for SNAP benefits, resulting in program expansions, experienced reduced suicidality and depressive symptoms at the population level (Austin et al., 2023).

SOCIAL POLICIES THAT PROMOTE MEB HEALTH

Infancy and Early Childhood

The 2019 National Academies report Vibrant and Healthy Kids found that home visiting during pregnancy and early childhood by a nurse, social worker, or early educator “improves a wide range of child and family

outcomes, including promotion of maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness” and recommended expanding evidence-based home visiting programs (NASEM, 2019c, p. 10). Estimates from U.S. Census Bureau data indicate that approximately five million pregnant women and families with children under 6 live in poverty (NHVRC, 2018); home-visiting programs reach only about 15 percent of them due to funding constraints (Zaid et al., 2022). Expanding funding for home visiting would need to be paired with training additional nurses, social workers, and early educators to deliver evidence-based interventions in families.

Early Childhood Care and Education and K–12 Education

The Administration for Children and Families, part of the Department of Health and Human Services, Head Start, and Early Head Start programs, reports that enrolled children have improved social, emotional, and behavioral development and fewer child welfare encounters related to sexual or physical abuse (ACF, 2024). As they mature, they are more likely to graduate from high school, attend college, and feel better prepared to be parents themselves compared with children who are not enrolled (ACF, 2024). However, similar to home-visiting programs, Head Start and Early Head Start services serve only 30 percent of 3- to 5-year-old children and 9 percent of infants and toddlers living in poverty, according to 2020–2021 data (First Five Years Fund, 2022). The need greatly outpaces the available resources. Although all children at or below 100 percent of the federal poverty level qualify for Head Start and Early Head Start, less than half of them receive the services (First Five Years Fund, 2022). Quality early childhood care and education is associated with improved MEB development, can mediate risk factors such as trauma and inadequate parental support (NASEM, 2019c; Penney et al., 2019), and may promote MH “through developmentally supportive learning opportunities and secure caregiving relationships” (Hutchins et al., 2023, p. 2).

National Academies reports have underscored how opportunities for educational attainment contribute to improved health, health equity, and well-being (IOM, 2013; NASEM, 2019b,c, 2023). But schools also contribute to MH directly, by implementing trauma-informed practices, providing MH services and curricula and teaching resources that center social and emotional learning, and creating safe and supportive learning environments (CASEL, n.d.; NASEM, 2019b). Federal policies, such as the No Child Left Behind Act, Every Student Succeeds Act, and IDEA, inform state education programming and set national standards and guidelines, including for implementing multitier systems of supports. Chapter 2 discusses school-based programs and other interventions in more detail.

Safety and Belonging

The 2023 National Academies report Federal Policy to Advance Racial, Ethnic, and Tribal Health Equity discussed the history of discriminatory federal policies including those that have harmed and traumatized specific communities, including people with disabilities, immigrants, people from certain racial and ethnic groups, and LGBTQ+ people.

Schools are an important setting for creating safe and supporting environments for youth development. The Promise of Adolescence recommended that to “[p]rotect the overall health and well-being of each student . . . school districts should enact policies and practices that promote supportive school climates and ensure safety for all students” (NASEM, 2019b, p. 199). For example, research shows that LGBTQ+ youth face greater risk of substance use, bullying, isolation, rejection, anxiety, depression, and suicide (Hafeez et al., 2017; Levengood and Hadland, 2024). Youth who are LGBTQ+ and are also Native American/Indigenous, Black, Latina/Latino, or multiracial, are more likely to have attempted suicide compared to their White LGBTQ+ peers (TTP, 2021). Seventy-two percent of LGBTQ+ youth reported symptoms of generalized anxiety disorder, and 62 percent reported symptoms of major depressive disorder in the past 2 weeks (TTP, 2021).

Since 2016, multiple states have enacted policies intended to enforce traditional gender norms that reflect binary sex at birth, from banning the use of bathrooms consistent with one’s gender identity to prohibiting classroom discussion about sexual orientation or gender identity. In 2023, 20 states enacted legislation limiting what LGBTQ+ people can do and the care they can receive (ACLU, 2024b). While it is still early to draw definitive conclusions about the effects of such policies, a 2023 national survey conducted by the Trevor Project reported that nearly one in three LGBTQ+ young people reported their mental health was poor most of the time or always due to anti-LGBTQ+ policies and legislation. Additionally, almost two in three LGBTQ+ youth said that hearing about potential state or local laws banning discussions about people like them in schools worsened their mental health (TTP, 2023).

An adverse policy environment can affect all LGBTQ+ communities, but young people are more vulnerable due to their dependence on the presence or absence of supports at school and at home (Hatzenbuehler, 2009). The literature also indicates that the social environment of sexual and gender diverse youth affects their behavioral health outcomes (Newcomb et al., 2019; Hatzenbuehler, 2011). For example, lower depression, suicidal ideation, and suicidal behaviors in gender diverse youth are associated with greater number of contexts where youth are referred to by their chosen name (Russell et al., 2018). There is also a growing body of work that illustrates that distal stressors such as structural stigma and discrimination

at different levels of government also influence the health outcomes of LGBTQ+ youth (Hatzenbuehler 2014, 2017; Hatzenbuehler and Link, 2014).

Ramos and colleagues (2023) found that:

New findings from the 2023 Behavioral Risk Factor Surveillance System (BRFSS) indicate that 25.3 percent of transgender and 26.4 percent of questioning students, compared to 8.5 percent of cisgender male students, missed school because they felt unsafe (Suarez, 2024). Of the 3.3 percent of U.S. high school students who identify as transgender, 72 percent reported feeling sad or hopeless (Suarez, 2024).

Research is needed to assess the effects on MEB health of recent state anti-LGBTQ+ policies on the MEB health of LGBTQ+ individuals, especially young people. State education and school district policies, in particular, appear to influence school climate, contributing to an environment that feels unsafe, unwelcoming, and even threatening. This stands in stark contrast to research highlighting the positive impact of social and emotional learning approaches in K–12 educational settings and the important relationship between schools and their communities (CASEL, n.d.; NASEM, 2019b, 2023).

Social Media Policies

The 2023 National Academies report Social Media and Adolescent Health examined the effects of social media on the mental and physical health of U.S. adolescents and made recommendations intended to “maximize the benefits

and minimize the harms” of social media (NASEM, 2024c, p. 2). The report highlighted, and the present committee endorses, the research needs discussed in that report, especially identifying what laws and regulations are needed to curb potential harms of exposure to unregulated violent or otherwise harmful content conveyed through social media (NASEM, 2024c).

In May 2023, the U.S. Surgeon General issued the Advisory on Social Media and Youth Mental Health, which called on policy makers, social media companies, researchers, youth, and their families to better understand the full impact of social media on MH, and maximize benefits and minimize harms (OSG, 2023). The advisory concluded that greater exposure to social media (more than 3 hours per day) is associated with twice the risk of poor MEB outcomes, such as depression and anxiety. Additionally, social media exposure can act as a mediator for other pathways to poor MEB outcomes, such as inadequate sleep.

In the last 5 years, Congress has introduced at least five legislative proposals related to further research and protecting user safety (NASEM, 2024c). In July 2024, the Senate passed the Kids Online Safety and Privacy Act¹ (which includes the Children and Teens’ Online Privacy Protection Act 2.0). As demonstrated in the proposed legislation, this topic warrants additional research to ascertain what guardrails may be necessary to mitigate potential harms of social media to the MEB health and well-being of youth.

As briefly discussed above, there are several domains where the relationship between MEB disorders and policies is clear, and others, such as social media, where there is a need for more evidence of effects on MEB health and well-being. Basing public policy on the best available knowledge is essential to enhancing protective factors and mitigating risk factors. As noted in Chapter 1, MEB disorders present major social and economic costs. It is crucial to identify, understand, and carefully consider the implications of policies on this public health issue.

RECOMMENDATION 7-1: In keeping with the Foundations for Evidence-Based Policymaking Act of 2018, federal and state policy makers should use the best available evidence to sustain, restore, develop, or de-implement social and economic policies, considering the direct or indirect effects of such policies on mental, emotional, and behavioral health and population well-being.

Policy makers have tools they can use to inform this work, including health impact assessments and a range of modeling approaches, including economic models as discussed in Chapter 5 (NASEM, 2016; NRC, 2011).

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¹ https://www.congress.gov/bill/118th-congress/senate-bill/1409 (accessed January 3, 2025).

Incarceration

Scale and Scope of Mass Incarceration

Mass incarceration is both a response to and risk factor for the disproportionately high rates of MEB disorders and substance use disorders (SUDs). The year 2023 marked 50 years of mass incarceration in the United States, defined by a period of unprecedented legal and policy decisions that have led to massive expansion of the use of incarceration as punishment, especially for drug use and crimes related to MEB disorders, and restrictions on the rights of people with criminal records, including limited access to publicly funded social services. Tens of millions of adults, especially those with low incomes and those from populations historically marginalized on the basis of their race or ethnicity, have been incarcerated, and almost 80 million have a criminal record (NCSL, 2023; Sawyer and Wagner, 2024). At any point in time, 60,000 children are incarcerated in juvenile facilities, and 5 million have parents who have been or are currently incarcerated (ACLU, 2024a; The Annie E. Casey Foundation, 2016). People released from incarceration face its “collateral consequences” of 42,000 laws and policies that create additional barriers for those with a criminal record, especially drug felonies, including to securing housing, transportation, health insurance, and employment (CSI, 2024). The effects of incarceration and stigma of a criminal record have lasting effects and spill over to the health of family members, and this risk is not shared equally across the population. Black men and women have an imprisonment rate six and two times more than their White counterparts, respectively (The Pew Charitable Trusts, 2023), leading to disproportionate effects on Black families (Lee, 2014). Almost 25 percent of Black individuals have three or more immediate family members who have been incarcerated, compared with 5 percent of White individuals (Sundaresh et al., 2021).

The Effect of Incarceration on MEB Health

Imprisonment and exposure to the conditions of confinement create new risks for MEB well-being. Furthermore, the overcrowding and exposure to violence that are commonplace in carceral facilities and the continued use of solitary confinement for punishment lead to severe psychological distress and MEB disorders, including anxiety, depression, and posttraumatic stress disorder (PTSD) (Edgemon and Clay-Warner, 2019; Huey and McNulty, 2005; Solitary Watch and the Unlock the Box Campaign, 2023). Incarceration is a broad structural pathway that exposes individuals to intersecting risks, including peer antisocial behavior, disruption of community connections, limited ability to practice prosocial behavior, and increased likelihood

of aggressive behavior due to the violent nature of prisons (Teplin et al., 2013, Tisdale, 2020). The lack of prevention programs and services, substance use treatment, and MH care within carceral facilities means that trauma exposure goes unaddressed, while substance use and MH problems worsen (Volkow, 2021). Studies of adults who have been incarcerated have shown robust and long-lasting relationships with certain disorders, including major depressive disorder, PTSD, and bipolar disorder; those who were incarcerated as children or with longer sentences had worse outcomes (Barnert et al., 2017). Upon release, “relapse to drug use can be fatal due to loss of opioid tolerance,” underscoring an opportunity and need for secondary prevention (Volkow, 2021, p. 2048).

For youth, having a criminal record diminishes one’s opportunities for protective factors for MEB health. It decreases educational attainment, residential independence, gainful activity, desistance from criminal activity and substance use, and impairs interpersonal functioning and parenting responsibility (Abram et al., 2017). The excess burden of felony drug convictions and imprisonment has radiating impacts on the children and families who are disproportionately incarcerated, such as Black, Latino, and Native American children and families. In 2021, Volkow writes, “Parents who are arrested can lose custody of their children, entering the latter into the child welfare system. According to . . . analysis by the Pew Charitable Trusts, 1 in 9 African American children (11.4 percent) and 1 in 28 Hispanic children (3.5 percent) have an incarcerated parent, compared to 1 in 57 White children (1.8 percent), (The Pew Charitable Trust, 2010),” (Volkow, 2021). Among American Indian and Alaska Native children in 2019–2020, 16 percent had a parent who was in jail or had served time when they were born (Casey Family Programs, 2023). Having a partner incarcerated is associated with symptoms consistent with major depressive disorder, higher levels of life dissatisfaction, and high rates of substance use and addiction (Wildeman et al., 2012). Children with incarcerated parents have been found to be more depressed; as young adults, they suffer from worse MEB outcomes compared to those whose parents have not been incarcerated (Geller et al., 2012).

Several states and jurisdictions have passed laws or instituted new policies to decarcerate, which have been rigorously studied, including addressing youth lawbreaking outside the criminal legal system; halting the use of confinement in response to probation violations and low-level drug offenses; and reinvesting dollars earmarked for youth incarceration to community alternatives to build community supports and prevention infrastructure (Mendel, 2023a; The Annie E. Casey Foundation, 2022). For example, to divert youth away from arrest and criminal charges, Florida passed a law to implement a civil citation program for juveniles (TJCHC, 2024). Civil citations are a civil alternative to arrest (DSCYF, n.d.). The U.S. Department of Justice (DOJ) evaluated the program, comparing those who were eligible

for civil citation but arrested with those given a civil citation. It concluded that civil citation reduced the likelihood of rearrest within the study’s 3-year follow-up period (Bales et al., 2019). Ohio passed a statute in 1993 to use a variety of strategies to decrease its juvenile incarceration rate, including the RECLAIM program, which gave jurisdictions choice in allocating dollars for adjudicated youth to either incarceration or community programming, allowing money to be kept locally and spent on developing supportive infrastructure in the community (Latessa et al., 2014; Lux et al., 2015; OJJDP, 1997). Low- and moderate-risk youth were much less likely to return to prison systems, and high-risk youth were also less likely to recidivate and be incarcerated after being supported by community programming compared with imprisonment. California passed Proposition 47 (2014),² which reduced penalties for certain lower-level drug and property crimes and showed modest but significant reductions in rearrest and reconvictions and no evidence that violent crime increased but some evidence that property crime did (NIJ, 2021). The state reallocated funds from incarceration to community-based treatment initiatives, such as MH and substance use disorder treatment, funds to K–12 schools, and victim services.

Most states have passed statutes to create problem-solving courts, also called “drug,” “treatment,” or “mental health” courts, that divert people with hazardous drug and alcohol use and MEB disorders from the carceral system (OJP, 2020). A recent study assessed the effect of a problem-solving court in the county on county-level overdose deaths and researchers found a significant effect in reducing county overdose mortality (Lindenfeld et al., 2022). Several studies have also found that providing medications for opioid use disorder for people in carceral facilities has shown reductions in overdose mortality (Lindenfeld et al., 2022). Twelve states, including New Mexico and New York, have passed legislation to mandate medications for opioid use disorder in carceral facilities (Weizman et al., 2021).

The Juvenile Detention Alternative Initiative (JDAI) is an example of a multisite implementation network of counties and states that has worked to reduce exposure to incarceration as a risk factor for MEB health by applying evidence-based laws, policies, and programs. Launched in the early 1990s, it was adopted by 300 counties across 39 states. It uses a variety of approaches to reduce youth incarceration, including passing laws that expand diversionary opportunities and reduce detention for probation violations, promoting cross-sector collaboration, implementing objective admissions criteria, and identifying policies that may have a harsher effect on racial or ethnic minority youth. The JDAI network is multisectoral, engages in community partnership, involves and consults those with lived

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² In November 2024, California voters passed proposition 36, which repealed some parts of Proposition 47 (Duara, 2024).

experience, and attends to and measures inequitable impact of policies on racial and ethnic minorities. Participating jurisdictions have seen reductions in detention among youth and state custody populations of more than 40 percent and more than 50 percent, respectively. These and other such efforts have achieved a 75 percent reduction in youth incarceration between 2000 and 2022; in 2022, 27,587 youths were held in juvenile justice facilities, down from 108,800 in 2000 (Rovner, 2024).

Policies exist in many jurisdictions that layer additional challenges to current and formerly incarcerated individuals, including denying access to protective factors, such as education and health care. A 2023 National Academies report examined the effects of federal policy on health disparities, with exclusions faced by previously incarcerated individuals as one specific example of policies that could be harmful to health and well-being. The report noted that although incarcerated people had been excluded from Pell Grant eligibility since 1994, Pell Grant access for people enrolled in qualifying prison education programs was reinstated in 2020. This, the report noted, is a promising example of how removing barriers to access to federal programs for specific populations can even the playing field in terms of the broad factors known to affect health (NASEM, 2023). The report also recommended a review of policies, such as those pertaining to Medicaid coverage, that exclude incarcerated people and other specific populations, for their effects on health outcomes (see Appendix F).

CONCLUSION 7-1: Evidence shows that incarceration has a detrimental impact on the mental, emotional, and behavioral health of millions of children and adults in the United States.

RECOMMENDATION 7-2: Federal, state, tribal, and county officials should enact evidence-based policies to divert from the criminal legal system and reduce reliance on incarceration where appropriate, while simultaneously building a robust community prevention infrastructure, thus enabling protective factors that support mental, emotional, and behavioral health.

As noted above, there are many opportunities to intervene before incarceration, such as civil court, drug courts, and community programming for youth, overseen by the criminal legal juvenile system.

Community prevention infrastructure refers to a range of investments and interventions that create protective factors and help reduce exposure to risk factors. For youth, school-based evidence-based programs, for example, may reduce problem behavior, strengthen coping skills and behavioral regulation, lessen aggressive behavior, and over the long-term lead to other positive outcomes, such as lower criminal legal system involvement (WSIPP, 2023).

ENVIRONMENTAL POLICIES THAT PROMOTE MEB HEALTH

Environmental policies represent a heterogenous set of interventions, but they share in common modifications to the environment to decrease or mitigate risk factors for MEB disorders, with causal pathways that generally include exposure to violence and trauma. Two protective factors discussed—mandating seat belt use and reducing lead exposure—are among the 10 greatest public health achievements of the 20th century (CDC, 2011).

Motor Vehicle Crashes

Research shows that policies can mitigate risk factors related to tobacco and alcohol. Policies setting age limits for sales, raising taxes, and limiting availability and advertising are among some of the approaches that states and localities have used to lower rates of drinking among teens and adults and thus reduce the public health effects (deaths and disease associated with alcohol, and also injuries from alcohol). The MEB disorders related to alcohol impairment are evident in motor vehicle crashes associated with driving while intoxicated—which is a major cause of PTSD, affecting an estimated 2.5–7 million U.S. people (Blanchard and Hickling, 2004). Each day, 37 people die in alcohol-impaired driving crashes, or one death every 39 minutes (NHTSA, n.d.). A range of evidence-based policy strategies can reduce driving while intoxicated and its social harms, but one of the most effective, taxation (which is inversely associated with binge drinking), has been eroded by inflation over the past 3 decades (Naimi et al., 2018). The 2018 NASEM report on alcohol-impaired driving called for increasing alcohol taxes and indexing them to inflation (this can generate funding for MEB promotion—see Chapter 5) and adopting universal primary seatbelt laws (i.e., a motorist can be stopped for not wearing a seat belt) to reduce motor vehicle accident fatalities.

Firearm Violence

Firearm violence—the intentional and unintentional injuries, deaths, and attendant physical and emotional trauma caused by exposure to firearm use—is a major contributor to poor MEB outcomes. The U.S. Surgeon General has highlighted the cascading harms to survivors and communities, including much higher rates of depression and psychiatric disorders (OSG, 2024). Although mental illness is frequently blamed for incidents of firearm violence, research indicates that it accounts for only 4 percent of violent acts (with or without firearms), and most people with mental illness are never violent (Swanson et al., 2015). In 2020 and 2021, more children and adolescents 1–17 years old died from injury by firearms (homicides, not suicide) than any other cause (Cabral et al., 2024; McGough et al., 2023;

Rossin-Slater et al., 2020). More than half of all suicide deaths are with a firearm, and 85 to 90 percent of all suicide attempts that involve a firearm are fatal (Drexler, 2016). Veterans and members of the military tragically experience elevated risk of suicide (Dempsey et al., 2019). Suicide rates are 57.3 percent higher among the veteran than among the age- and sex-adjusted non-veteran U.S. population, and 72.2 percent of veteran suicides are by firearm compared to 52.2 percent of non-veterans (OMHSP, 2022, 2023).

As noted in the 2024 Surgeon General’s Advisory, “beyond the profound consequences of surviving a firearm-related injury, those who do not experience direct bodily harm often grapple with MEB consequences related to firearm violence exposure, including community members, children and adolescents, and families” (OSG, 2024, p. 14). In her presentation to the committee, Therese Richmond of the University of Pennsylvania echoed this finding, describing firearm-related harms as a pyramid, with deaths at the top, morbidity in the middle, and myriad effects on the MEB health of individuals and families and well-being of communities at the base (Richmond, 2024). The morbidities among survivors include MEB issues (such as PTSD and depression), and those indirectly exposed to firearm violence are more likely to receive a MH diagnosis or report symptoms of depression and drug and alcohol use (Magee et al., 2023; Rheingold et al., 2012). Smith and colleagues (2020b) found that 24 percent of participants in the Survey of Police-Public Encounters across four urban areas reported exposure to firearm violence fatality and those exposed had “significantly higher levels of psychological distress, depression, suicidal ideation, and/or psychotic experiences compared to those not exposed” (p. 1).

Richmond made some key points about how the relationship between MEB health and firearm violence needs to inform the infrastructure to prevent MEB disorders. She underscored that the induction period for firearm violence is not a split second (the finger on the trigger) but can be quite long, allowing consideration of a prevention infrastructure that addresses joint risks for both firearm violence and MEB disorders. She also noted that the prevention infrastructure for MEB disorders needs to be maximally accessible to youth, families, and communities at risk for firearm violence (Richmond, 2024).

There is ample evidence that firearm violence contributes to MH disorders for children and adolescents. Repeated exposure to firearm violence, particularly in neighborhoods with high crime rates, can lead to chronic PTSD, affecting a child’s functioning in school and social settings (Collins and Swoveland, 2014; Panchal, 2024). In addition, Song and colleagues (2023) analyzed data from 2007–2021 to assess the impacts of firearm injuries on 2,052 child and adolescent survivors and their families, finding increases in pain disorders (117 percent), psychiatric disorders (68 percent), and SUDs (144 percent) among survivors. Health care spending surged by $34,884 per survivor in the first year (Song et al., 2023).

Turning to indirect effects, firearm violence affects not only the direct victims but also their families and communities, creating cycles of trauma and worsening MEB outcomes. Families of victims often experience profound psychological distress, including grief, anxiety, and depression (Panchal, 2024). Among rural youth ages 13–18 interviewed at Iowa’s FFA (formerly Future Farmers of America) leadership conference, more than one-third said “they knew someone who had been killed or injured by a firearm,” more than “two-thirds knew of someone who had died or was injured unintentionally” by a firearm, and 30 percent “knew of someone killed or injured intentionally” by a firearm (Jennissen et al., 2021, p. 1). Song and colleagues (2023) found that firearm injuries among children and young adults had harmful effects on their family members. Mothers in particular faced increased MEB challenges, with a 30 percent rise in psychiatric disorders for parents and a 75 percent increase in MH visits for mothers (Washburn, 2024). Box 7-1 outlines a community coalition’s multi-faceted work to address community violence as a cause of

poor MH and provides an illustration of programming that could be paired with municipal or state-level policies that promote safety.

Community violence is not randomly distributed but is highest in communities that experienced discriminatory banking practices on the basis of race and ethnicity under the Home Owners’ Loan Corporation in the mid-20th century (Poulson et al., 2021). Firearm violence disproportionately affects Black children and adolescents, with higher rates of exposure to assaults, police shootings, and community violence. Black individuals are nearly 14 times more likely to die from firearm homicide than White individuals, and inpatient admission rates for firearm-related injuries are 9 times higher among Black patients (Schnippel et al., 2021; Semenza et al., 2024). Bor and colleagues (2018) used data from the 2013–2015 BRFSS and Mapping Police Violence databases to examine the MEB impacts of police killings of unarmed Black individuals on other Black adults, finding that each additional police killing in the respondent’s state of residence was associated with 0.14 additional poor MH days.

Although mass shootings do not account for the majority of incidents of firearm violence, they have a profound psychological impact on both the individuals directly involved and the broader community. Rossin-Slater and colleagues (2020) examined the impact of local exposure to school shootings on youth antidepressant use. The results showed a 21.4 percent increase in antidepressant use among youth within 2 years of fatal shootings.

A range of interventions have been established as promising at preventing one or more negative health outcomes, including suicide: one 2024 systematic review found that laws requiring secure storage of firearms and preventing child access can reduce rates of suicide, unintentional injury and death, and violent crime (Smart et al., 2024). Emerging evidence indicates that these programs could be implemented at scale (Beidas et al., 2024). Anderson and colleagues (2021) found that child access prevention laws reduced juvenile firearm-related homicides by up to 17 percent. Grossman and colleagues (2005) demonstrated that secure storage was also associated with reductions in youth firearm-related suicide and accidents, which reduces exposure to trauma, preventing the onset of aforementioned MEB issues, such as PTSD.

Smart and colleagues’ (2024) systematic review also found that minimum age requirements for purchasing a firearm reduce suicides among young adults. Anestis and Anestis (2015) found that four policies (waiting periods, background checks, gun locks, and open carry permits) were all associated with a lower rate of suicide overall and by firearms specifically; conversely, repeal of such laws led to an associated increase. Researchers in Washington state found that requirements for a permit to purchase assault rifles reduced firearm violence incidents, including those with an assault weapon for individuals under 21 (Bhullar et al., 2024).

Research indicates that red flag laws, also called “Extreme Risk Protection Orders” (ERPOs), civil court orders that temporarily prevent the purchase or possession of firearms, are effective in preventing suicides and homicides or mass shootings (Swanson, 2019; Wintemute et al., 2019; Zeoli et al., 2019). The 2022 Bipartisan Safer Communities Act included $750 million in incentives for states to implement ERPOs and other crisis intervention approaches (Geller, 2023). In March 2024, DOJ launched a National ERPO Resource Center to assist in implementation (OPA, 2024). A composite measure of state-level firearm legislation for 1991–2017 found that states with a higher number of safety policies experienced a lower rate of suicides and homicides (Gunn et al., 2022). Research shows that firearm violence can be heavily concentrated in low-income communities and communities or subpopulations marginalized on the basis of race and ethnicity, and lead to a cycle of violence that leads to trauma and jeopardizes MEB health. Community violence intervention (CVI) uses “evidence-informed strategies to reduce violence through tailored community-centered initiatives” and has

been recently supported through a historic federal investment launched by DOJ in FY 2022 (CGVS, n.d.; OJP, n.d.). These approaches are community driven and multisectoral. In 2021, the City of Baltimore released its first Community Violence Prevention Plan, which included support of the CVI ecosystem, including Safe Streets, a violence interrupter program that uses trusted messengers to serve as intermediaries and de-escalate violent situations. The evaluation showed that Safe Streets decreased homicides and nonfatal shootings (Webster et al., 2023). A recent randomized trial of another CVI, Rapid Employment and Development Initiative Chicago, which includes cognitive behavioral therapy and access to social services, found a 65 percent decrease in shootings and homicide arrests (Bhatt et al., 2023).

According to the Department of Veterans Affairs, lethal means safety counseling (LMSC) “is a patient-centered counseling strategy that aims to promote safety behaviors by aligning evidence-based recommendations with patients’ preferences and values.” It is a health care–centered approach that involves asking if a person at risk of injury or death has access to lethal means and working to reduce that access until the risk subsides (U.S. Department of Veterans Affairs, n.d.; EFSGV, n.d.). A recent review found that LMSC changed behaviors in 14 out of 19 studies, although the quality of these studies varied (Spitzer et al., 2024). A 2021 randomized trial of LMSC coupled with cable locks, however, did find an increase in protective behaviors (Anestis et al., 2021).

CONCLUSION 7-2: Evidence shows that firearm violence erodes mental, emotional, and behavioral (MEB) health, directly contributing to poor MEB outcomes, including suicide, depression, and anxiety, especially for youth and heavily affected communities.

RECOMMENDATION 7-3: Federal, state and local policy makers should implement evidence-based policies to prevent firearm violence—a risk factor for mental, emotional, and behavioral disorders—including but not limited to safe and secure gun storage, community violence interventions, and lethal means safety counseling.

Lead Poisoning Prevention

Lead poisoning prevention is a major component of public health programming at the federal, state, and local levels. Because high blood lead levels cause neurological harm, they are associated with lower levels of educational attainment, more behavioral problems (e.g., in school), and other risk factors for poor health and social outcomes, including juvenile detention (NASEM, 2019a, 2024b). Childhood lead exposure is also linked with mental disorders in adulthood (Reuben et al., 2019). Despite the decrease

in lead exposure owing to federal regulations and related environmental changes (removing lead from gasoline), approximately 500,000 U.S. children ages 1–5 years have blood lead levels at or above the CDC blood lead reference value of 5 μg/dL (Dignam et al., 2019). Those most at risk for lead exposure are from low-income and minoritized communities (Yeter et al., 2020). The effective interventions needed to address lead hazards are well documented, and National Academies and other reports have called for such interventions, ranging from removing lead water service lines to increasing the enforcement of the Environmental Protection Agency rule that “requires lead-safe renovation, repair, and painting” (NASEM, 2019c, p. 425).

Neighborhood Factors

The quality of neighborhoods matters for MEB health. Policies can support healthy neighborhoods and built environments. One well-known example is the federal Moving to Opportunity experiment, which demonstrated the impact of neighborhood on adult well-being. Researchers found that living in a low-poverty neighborhood had positive impacts on adults’ mental and physical health, including decreased rates of depression. Evidence indicates that neighborhood characteristics have considerable effects on MH, well-being, and safety (South et al., 2018; Tach et al., 2016). For example, Branas and colleagues (2016) found that blight remediation measures significantly reduced firearm violence and provided “taxpayer and societal returns on investment for the prevention of firearm violence” of “$5 and $79 for every dollar spent on abandoned building remediation and $26 and $333 for every dollar spent on vacant lot remediation” (p. 2158). Enhancing green spaces, such as greening vacant lots and building parks, is associated with multiple positive outcomes, including enhanced community safety and greater well-being/lower levels of stress (Ashcraft et al., 2024; Hunter et al., 2019).

INCLUDING MEB HEALTH OUTCOMES IN POLICY RESEARCH

Research from various federal agencies has demonstrated that policies can positively impact MEB health and resilience (Purtle, 2016). Examples include housing vouchers, rental assistance, urban green spaces, and the Medicaid Early and Periodic Screening, Diagnostic and Treatment benefit (Ashcraft et al., 2024; Branas et al., 2011; Hunter et al., 2019; PD&R, n.d.; Rosenbaum, 2016). However, MEB health outcomes are not consistently included as a policy target, which represents a missed opportunity to learn whether and to what extent policies are effective at preventing MEB disorders.

RECOMMENDATION 7-4: The Department of Health and Human Services (through the National Institutes of Health, Centers for Disease

Control and Prevention, and Centers for Medicare & Medicaid Services), and the relevant research entities in the Departments of Defense, Education, Housing and Urban Development, Justice, and Veterans Affairs should direct more targeted funding to research that assesses mental, emotional, and behavioral health and population well-being outcomes related to specific policies directed at social, economic, and environmental factors. Studies should include direction and strength of associations, as well as an assessment of causality.

In closing, the overview of implementation considerations for policy provided in Box 7-2 restates the earlier description of the steps for program implementation.

REFERENCES

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³ https://implementationresearch.wustl.edu/support-your-research/di-methods-tool-2/ (accessed January 16, 2025).