Congressional Briefing on Children’s Mental Health--October 10, 2007

Thank you for the opportunity to meet with you today. I am very appreciative of your work and passion on what has become a public health crisis, the behavioral health of our children, youth and families. Urgent steps must be taken to address this crisis and to ensure the health and wellness of children and their families to lead productive lives.

I am Ken Martinez, licensed clinical psychologist and Principal Research Analyst with the American Institutes for Research. I am clinical assistant professor of psychiatry at the University of New Mexico and have been for the past 29 years. Prior to my current position I was New Mexico’s children’s behavioral health director.

I am particularly grateful to our own Senator from New Mexico, Senator Pete Domenici and his staff. Senator Domenici has championed mental health his entire professional career. We are indebted to your commitment and passion. Thank you, Senator Domenici.

Research has demonstrated that culture and language profoundly affect the health and quality of care received by children of color, especially those that speak a language different than English. Failure to consider cultural and linguistic factors in outreach, engagement, screening, assessment and treatment can lead to adverse consequences, including harm or iatrogenic effects (McCabe, 2002). I firmly believe that our research has to be culturally sound and translate into culturally appropriate practice and effective policy to better the lives of all children, especially those that have historically been left behind.

Cultural and linguistic competence in behavioral health care is a minimum standard that we can no longer afford to disregard.

Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross–cultural situations. (Cross et al., 1989; Isaacs & Benjamin, 1991)

Linguistic Competence is providing readily available, culturally appropriate oral and written language services to limited English proficiency (LEP) members through such means as bilingual/bicultural staff, trained interpreters, and qualified translators. (Agency for Healthcare Research and Quality, 2003)

It is incumbent upon us to adopt and effectively utilize culturally and linguistically appropriate research, measurement and practice. Eliminating behavioral health disparities due to race or ethnicity is an imperative that we must all take on and requires our commitment to solve. I would like to address five areas today that require our attention.

  1. Behavioral health disparities do exist for children and families of color.

  2. Suicide is ravaging our communities of color.

  3. A word of caution about the use of generic Evidence Based Practices (EBPs) and the quality of care that children, youth and families of color receive.

  4. The “dual pathways to care” or disproportionality of children and youth of color in the juvenile justice and child welfare systems must be eliminated.

  5. We can prevent tragedies like Virginia Tech with culturally appropriate outreach, engagement and retention strategies.

Behavioral health disparities do exist for children and families of color.

  • A significant proportion of our children of color are uninsured. On the average 22% (3 million) Latino children, 19.7% of African American children and 12.4% of Asian/Pacific Islander children are uninsured, compared to 11.3% of non-Hispanic White children. (US Census Bureau, 2005)

  • 88% of US born Latino children/youth have unmet mental health needs, the highest of all ethnic/racial groups which is especially concerning given the national estimates suggesting that Latino adolescents have the higher rates of suicidal thoughts, depression and anxiety symptoms and greater rates of dropping out of high school than White adolescents; Latino children with mental health problems had greater odds of having no care, or unmet need, than White children, by a ratio of 1 : 2.66. (Kataoka, Zhang, Wells, 2002; Centers for Disease Control and Prevention, 1999)

  • Latino children and youth utilized mental health services at the lowest rates compared to all other ethnic/racial groups of children and youth.

  • 7.6 to 10.5 % of youth of color ages 12-17 have had a Major Depressive Episode between 2004 and 2005. (SAMHSA National Household Survey on Drug Use and Health, 2006)

  • Asian American and Latina female adolescents have the highest rates of depression. (Commonwealth Fund, 1997)

  • Uninsured children had higher rates of unmet need than publicly insured children, suggesting that Medicaid and SCHIP offer an important safety net. (Kataoka, Zhang, Wells, 2002)

  • While immigrants in general appear to have lower rates of mental disorders than their US born counterparts (50% less in some studies), second and later generations of immigrants have a higher risk for mental disorders than their parents, e.g. the prevalence of alcohol and other drug abuse was more than 4 times higher in US born individuals of Mexican descent than those born in Mexico. (Vega, Kolody, Aguilar-Glaxiola, Alderate, Catalana, Carveo-Anduaga, 1998)

  • Black and Latino youth are identified and referred for behavioral health treatment at the same rates as the general population, but are less likely to receive specialty mental health or medication. (Kelleher, 2000)

Suicide is ravaging our communities of color.

  • Suicide is the 3rd leading cause of death among adolescents age 15-19.

  • Latina adolescents ages 14-18 are most likely to attempt suicide, 1 in 5 (20%) (National Governors Association, 2005; Centers for Disease Control and Prevention, 2005) compared to 9.3% of White non-Hispanic adolescents. (National Adolescent Health Info Center, 2006)
    Only 1/3 receive treatment.

  • American Indian adolescent males have the highest suicide rate of all ethnic/racial groups in the US with 24.3/100,000 compared to 12.7/100,000 for White non-Hispanic males. (Freedenthal and Stiffman, 2007)

  • Among 15-18 yr olds, there are 11 suicides each day.
    Of these suicides, about 40% had contact with a primary care provider within the last month of their life. (Luoma, et al., 2002)

  • States spend over $1 billion on medical costs associated with suicides and suicide attempts by youth under age 20. (National Governors Association, 2005)

A word of caution about the use of generic Evidence Based Practices (EBPs) and the quality of care that children, youth and families of color receive.

  • Behavioral health care for children, youth and families of color is not always culturally or linguistically appropriate because it is not always based upon the cultural values, beliefs, practices and traditions that families of color come from.

  • Chicken soup may be remedy of choice for the common cold in many cultures, but in other situations, medication and the dosage for a White child can kill an Asian American child or cause irreparable side effects for a Latino or African American child.

  • We must assure that Evidence Based Practices as currently defined and used are well studied in populations of color and, when appropriate, are modified to include culturally-appropriate strategies

  • We must conduct studies of the kind of care and practices that have traditionally been used in communities of color to determine whether they are effective

  • We must listen to what communities are telling us works and integrate and test them in scientific studies of practice so that such practices are not discarded prematurely

  • We must study other culturally-based interventions and approaches such as engagement strategies, cultural brokers, promotoras and primary care integration that have worked in communities.

  • Because funding that mandates the exclusive use of EBPs has the potential to drive small behavioral health agencies and organizations out of business, we need to use unique strategies to disseminate and teach EBPs in such agencies and settings so as not to diminish our current capacity to serve cultural ethnic/racial communities appropriately, effectively and efficiently.

The “dual pathways to care” or disproportionality of children and youth of color in the juvenile justice and child welfare systems needs to be eliminated.

Juvenile Justice

  • Youth of color are being criminalized solely on the basis of experiencing a mental illness.

  • The rate of mental disorders is high, between 65% to 73%, among both boys and girls who are detained. (Teplin, 2002)

  • A 1999 survey by the National Alliance for the Mentally Ill (NAMI) found that 36% of their respondents reported having to place their children in the juvenile justice system in order to access mental health services that were otherwise unavailable to them.

  • The U.S. General Accounting Office (GAO) found that in 2001, parents placed over 12,700 children into the child welfare or juvenile justice systems in order to access mental health services.

  • The national juvenile justice custody rate for youth of color to that for non-Hispanic White youth was 2.6 to 1 in 2003.

  • In 2003, for every 100,000, 348 Latino youth were in juvenile custody compared to 190 Caucasian youth--almost twice the incidence.

  • In 2003, more than 59,000 youth of color were locked in juvenile facilities, 61% of total youth in custody, while they are only 1/3 of the youth population, and 19% of them were Latino. (Snyder, Howard and Sickmund, 2006)

  • Youth of color are being criminalized and locked up at a disproportionate rate and are not being treated in the community or in jail. (Coalition on Juvenile Justice, 2000; Snyder, Howard and Sickmund, 2006; Martinez, 2007)

  • Juvenile jails are becoming the de-facto juvenile psychiatric hospitals of today.

What Works in Juvenile Justice

  • We have strategies that work such as Juvenile Detention Alternatives Initiative (JDAI) in which communities develop alternatives to detention without jeopardizing safety of community.

  • Through JDAI, the gap between white and youth of color in likelihood of being detained decreased.

  • For African American and Latino youth, the number admitted to detention dropped by half. (Burns Institute & Casey Foundation, Juvenile Detention Alternatives Initiative, 2002)

Child Welfare

  • Children of color make up 42% of the population in the U.S., yet 57% of children in foster care are youth of color. (U.S. Census, 2004; Child Welfare League of America, 2007)

  • Up to 85% of children in foster care have an emotional, behavioral or substance abuse problem.

  • Blacks, Hispanics and Asian/Pacific Islander have disproportionate rates of maltreatment investigations.

  • African Americans make up 15% of the total population under 18, yet 40% of children in foster care are African American and they are placed in out-of-home placement more frequently and for longer periods of time than any other group of children. (US Census, 2004; Child Welfare League of America, 2007)

What Works in Child Welfare

  • There are strategies that work such as disparity reduction in child welfare that combines business principles with behavioral intervention research which has lead to base rates for removal of African American youth to decrease by more than 50% from 24/1000 to 11/1000. (Redd, Bell, et al, 2005)

We can prevent tragedies like Virginia Tech by: 1) focusing on culturally appropriate community outreach, engagement and treatment; and 2) ensuring system collaboration with cultural communities.

  • Early warning signs, including early unusual behaviors were all indicators to signal the need for intervention with Seung Hui Cho, a young man with a serious emotional disorder.

  • Culturally, in the Korean culture and in most communities of color, mental health is highly stigmatized.

  • While his family recognized these atypical behaviors they were not able to get engaged in the mental health system.

  • We are increasing behavioral health disparities with youth of color when we don’t recognize the different cultural needs and culturally specific approaches required in engaging culturally diverse youth and families and de-stigmatizing mental health care.

  • This tragedy highlights the presence of mental health issues in our cultural communities and the lack of connection with them.

Proposed Solutions

The solutions are common sense solutions.

  • We must adequately insure all children. No child should be left uninsured. Health care that includes health promotion, prevention and early intervention is by far the best investment in children.

  • Culturally and linguistically appropriate care must be integral to the health care delivery system.

  • A culturally and linguistically competent, accessible and available bi-lingual and bi-cultural workforce is essential.

  • Culturally and linguistially appropriate quality care must be provided to our children, youth and families of color. “Off the shelf” manualized approaches that are not standardized on the populations they are used on and are not based upon the cultural world view, values, beliefs and traditions of children, youth and families of color are insufficient. Community defined evidence approaches need to be discovered, validated and funded.

  • Disproportionality in the juvenile justice and child welfare systems must be addressed through multi-level approaches that include diversion, community based alternatives and early behavioral health intervention and treatment.

  • Suicide and human tragedies that are ravaging our communities and schools can be addressed through culturally appropriate outreach, engagement and retention strategies that meet the cultural and linguistic needs of our children and youth of color. These pre-treatment interventions are not now funded, yet they are so critical to engaging our diverse populations.

  • The SAMHSA sponsored National Network to Eliminate Disparities (NNED) in Behavioral Health Care is one vehicle to organize, network and convene all national efforts to eliminate behavioral health disparities in behavioral health for cultural ethnic/racial groups.

  • Initiatives that the NNED is sponsoring:

    • The discovery of Community Defined Evidence Models to determine measures and practices that work in ethnic/racial communities;

    • Anti-Stigma and Behavioral Health Education Campaigns for Diverse Groups in partnership with the Ad Council and diverse community leaders to develop culturally appropriate messages, vehicles and strategies for reaching diverse communities

    • The development of community engagement models

    • Workforce development

    • Integration of health and behavioral health

Policy Implications

  • Federal, state and local governments along with policy makers, researchers, funders and communities, families and youth jointly, must work in partnership to improve the health and well-being of our children, youth and families. Alone, no one can do it.

  • When we look at health disparities legislation, we also need to look at eliminating behavioral health disparities in the same legislation. Behavioral health has major implications for general health. The effects of trauma, domestic violence, post traumatic stress, depression and anxiety are direct predictors of physical health problems. Mental health and physical health are inextricably linked as evidenced by the Adverse Childhood Experiences Study. (Chapman, et al., 2007) Behavioral health must be included in health disparities legislation.

  • Congress has the authority to ask the executive branch about the federal agencies’ investments and portfolios in disparities, such as the investment in reducing disparities in behavioral health care or in child welfare and juvenile justice. Federal agency investment and priorities must include elimination of behavioral health disparities.

  • We need policies that address recruitment and retention of a qualified behavioral health workforce to eliminate our workforce crisis.

References

Agency for Healthcare Research and Quality. What Is Cultural and Linguistic Competence? February 2003. Rockville, MD.

BigFoot, D.S., Bonner, B. L., Honoring Children, Mending the Circle, National Child Traumatic Stress Network, 2006.

Chapman D.P., Dube S.R., Anda R.F. Adverse childhood events as risk factors for negative mental health outcomes. Psychiatric Annals. 2007 37(5):359–364.

Freedenthal, S. and Stiffman, A.R. (2007) “They might think I was crazy:” Young American Indians’ reasons for not seeking help when suicidal. Journal of Adolescent Research, 22, 58-77.

Institute of Medicine (2002). Reducing suicide: A national imperative. Washington, D.C.: National Academies Press.

Kataoka, S. H., Zhang, L., Wells, K.B. (2002) Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance status. American Journal of Psychiatry, 159(9), pp1548-1555.

Kelleher, K. (2000). Primary care and identification of mental health needs. In U.S. Public Health Service, Report of the surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. (pp. 21-22). Washington, D.C.

National Governor’s Association (2005). Issue Brief: Suicide Prevention: Strengthening State Policies and School-Based Strategies.

National Adolescent Health Information Center. (2006). Fact Sheet on Suicide: Adolescents and Young Adults. San Francisco, California: Author, University of California, San Francisco.

Ringel, J. & Sturm, R. (2001). National estimates of mental health utilization and expenditures for children in 1998. Journal of Behavioral Health Services and Research, 28(3) 319-332.

Substance Abuse and Mental Health Services Administration National Household Survey on Drug Use and Health, 2006.

Teplin, L., Abram, K. McClelland, G., Duncan, J. & Mericle, A. (2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59, 1133-1143.

Vega, W. A., Kolody, B., Aguilar-Glaxiola, S. Alderate, E., Catalana, R. and Carveo-Anduaga, J. (1998) Lifetime prevalence of DSM II-R psychiatric disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry, 156, 928-934.

US Census, US Census Bureau 2004/2005.