Cover Story

One in five children and teens suffers from mental health problems, and the number is growing. The World Health Organization estimates that by 2020, neuropsychiatric disorders in children will swell by 50 percent compared with other health-related problems, making them one of the five leading causes of childhood illness, disability and death. While it is unclear exactly why the numbers are rising so rapidly, many experts believe it is related to increased stress in children and families and better diagnosis of existing problems.

Yet, despite the fact that these conditions exact heavy tolls on the young--including substance abuse, academic failure, criminal involvement and suicide--less than half receive treatment, according to several recent reports, including those by a 2003 APA task force and a recent presidential subcommittee on children's mental health. Worse yet, only 20 percent get the right kind of treatment, the reports note.

Psychology is working to change that. Beginning with its involvement in the landmark 2001 Surgeon General's National Action Agenda for Children's Mental Health and through a number of efforts since (see box, page 41), the field has placed children's mental health squarely on the map and is championing what amounts to a new system of care.

"There is a more universal recognition that we face an epidemic of children's mental health problems in this country," says Barry Anton, PhD, a pediatric mental health expert at the University of Puget Sound who chaired the 2003 APA Task Force on Psychology's Agenda for Child and Adolescent Mental Health, "and with it, the awareness that we need an action plan to address this epidemic and get children and families the help they need."

Such an action plan--similar across the variety of reports on the subject--differs markedly from business as usual, notes psychologist E. Wayne Holden, PhD, a 2003 APA task force member and president of ORC Macro Inc., a research firm that studies public interest issues for the federal government. Unlike the current system, which fragments care by shuttling children into a variety of uncoordinated systems, the new paradigm puts children's needs at the center and brings services to them through coordination of agencies, involvement of communities and direct work with families, he says.

"We need to take a holistic public health approach to children's mental health," Holden explains. "That means providing services and support across a variety of different systems over several years, so that we can foster children's ability to live successfully in all parts of their lives."

A new look at structure

The broadest way to achieve this goal, psychologists involved say, is to change the structure of the system. In essence, it must move from a model of "silos"--where systems work independently, often at cross purposes--to one where they work in collaboration, Holden notes.

Several states already are starting to do this, says psychologist Larke Huang, PhD, who co-chaired the children and family subcommittee of President Bush's New Freedom Commission on Mental Health (NFC) along with psychologist Steven Mayberg, PhD, director of California's Department of Mental Health. New Mexico, for instance, is redesigning its children's mental health delivery system to incorporate principles of cooperation and coordination, she says. Likewise, Illinois has formed the Children's Mental Health Partnership, a governor's-level group that aims to foster unity among child mental health agencies.

Besides these efforts, Huang, Mayberg and other NFC commissioners have met with other state leaders, encouraging them to re-examine their child-serving systems, says Huang, who is managing director of the American Institutes for Research in Washington, D.C., a research, policy and technical assistance center devoted to bettering the lives of children and families.

Psychologist Patrick Tolan, PhD, who directs the Institute for Juvenile Justice Research at the University of Illinois at Chicago, is involved in such a project at the city level in Chicago, aimed at helping young people with behavioral problems and courting trouble with the law. He is consulting with three traditionally turf-bound systems that intersect with these kids--the police, the school system and the child-welfare system--to help them find ways to work together more effectively.

"The aim is to avoid redundant, uncoordinated services," he says, "and to give good mental health care while at the same time respecting legal limitations."

The slow pace of the project underscores the entrenched nature of the task. "It takes a long time for the people in these systems to trust one other, to feel that their perspectives are being heard, and to feel safe in sticking their neck out a little bit," he says. Nevertheless, the group, run in collaboration with the mayor's office and other city and county agencies, is starting to break down barriers and open up new, less punitive ways of thinking about the fate of these young people, he says.

Such changes also are happening within systems, says University of Texas at Austin school psychology professor Deborah Tharinger, PhD, a member of the 2003 APA task force. Some schools, for example, are consciously fostering a "wellness orientation" that encourages tolerance and inclusion and discourages bullying and harassment, she says.

"Whenever you can create a safe environment where kids don't feel as stressed," she says, "they're going to be much more capable of using their strengths. These kinds of holistic approaches are as or more important than treating individual disorders."

A new look at service delivery

Besides making structural changes, a new system aims to deliver services more effectively, by making them easier to access and better tailored to those who use them, child experts say.

Community involvement is one way to do this, says Nadine Kaslow, PhD, a family psychology expert at Emory University and a 2003 APA task force member. "There is often a real disconnect between what goes on in these communities and the empirically supported treatments developed by psychologists," she says. "We need to find the community ingredients that will make these projects work."

One such effort is the Strong Communities Initiative, a comprehensive, community-based project designed to prevent child abuse and neglect in South Carolina. The initiative, funded by the Duke Endowment, builds systems of support for families of young children with the goal of increasing every family's connection to their neighbors and community resources, says psychologist Patricia Y. Hashima, PhD, a project researcher and a member of the 2003 task force.

One of the components of the project provides user-friendly mental health services to children in kindergarten and their parents, with the aim of giving families easy access to help when and where they need it, Hashima says. To avoid stigma, for instance, mental health counselors are called family support workers, and they offer creative services like breakfasts for parents on the first day of kindergarten and drop-in sessions for parents throughout the school year. The program's philosophy, based on a report of the U.S. Advisory Board on Child Abuse and Neglect, "is that successful prevention programs must mobilize the entire community to create a society where people care about, watch and support each other's families," Hashima explains.

Another new service-delivery approach is simply to apply the best of what is already available, such as innovative programs with a proven track record (see page 44) and solid prevention and early-intervention services. "What is really needed," says Tolan, "is to identify kids with behavior problems early on and to get them involved in interventions we know will work."

Interestingly, some of the best approaches that aren't being widely used are those that save the most money, says sociologist John Landsverk, PhD, director of the Child and Adolescent Services Research Center at the Children's Hospital in San Diego, who has written extensively about effective treatment models. Several innovative programs now allow at-risk youth to stay at home or in foster-care homes rather than entering the juvenile justice system (see July/August 2003 Monitor), for example. "Yet there is no evidence whatsoever that the foster-care system is using them," Landsverk says.

A new system also must devise creative ways to reach underserved youngsters more effectively, believes Huang. Often, children at greatest risk of developing mental health and related problems--including poor and rural minority children--are least able to access appropriate services, she says.

A new look at roles

Finally, psychologists involved in a new system must be willing to take on roles that allow for these improved methods of service delivery, child experts believe.

One such role is to make family members partners in care versus targets of treatment, says Tharinger. To this end, she and colleague Stephen Finn, PhD, are beginning the first-ever evaluation study of an approach called Therapeutic Assessment, which strives to break down traditional walls between assessment and treatment. The eight- to 10-week intervention, developed by Finn, involves family members at all stages: It gears the assessment toward questions the family has asked at the beginning, lets parents observe their child's behavior through a one-way mirror while the child is participating in the direct assessment and includes a member of the assessment team behind the mirror to discuss the process with parents as it unfolds, Tharinger explains.

Such an approach "can help parents get a different perspective on their child, a more compassionate view, and let them see how they might be contributing to some of their child's struggles," Tharinger comments. Given its dynamic nature, the method also opens up new ways to view and address children's problems, she believes.

Psychologists also will be called on to act as educators and consultants--in the courtroom with judges and probation officers, for example--and to work in nontraditional settings and on interdisciplinary teams, Huang notes.

An effort worth making

Creating a new system will not come easily, child experts acknowledge. Besides the effort of overcoming structural and delivery barriers, these new approaches require more funding than is currently available, whether for training psychologists in these new roles, bringing more psychologists into the system or adequately addressing systemic changes.

That said, Tolan notices one big difference between the current climate and that of a few years ago.

"What counters my pessimism," the veteran children's advocate says, "is that conversations are becoming more about, 'How do we make this happen?' instead of, 'This will never happen, but we should still tell people it's a good thing.'"

Tori DeAngelis is a writer in Syracuse, N.Y.