June 22, 2000

Beverly L. Malone, Ph.D., R.N., F.A.A.N.
Deputy Assistant Secretary for Health
Office of the Surgeon General
Washington, DC 20201

Dear Dr. Malone:

On behalf of 159,000 members and affiliates of the American Psychological Association (APA), I write to offer our comments to the five questions posed by the Surgeon General in his letter of June 9, 2000. We commend the Surgeon General’s office and the Administration for coordinating the upcoming national conference on children’s mental health and for making the planning process open for input and discussion. The comments set forth below reflect critical points made by many of our members with relevant knowledge and expertise in children’s mental health.

In light of our members’ impressive research and clinical experience with young children in school, primary care, and other clinical settings, APA, and the field of psychology, have much to contribute to a close examination of these issues. APA’s commitment to children’s mental health is evidenced by the number of divisions of the membership devoted to children’s concerns, including divisions of developmental psychology, clinical child psychology, pediatric psychology, school psychology, and family psychology. That commitment is further demonstrated by APA’s governance structure, which includes the Committee on Children, Youth and Families, as well as various task forces devoted to family and adolescent issues.

We thank you for continuing to recognize APA’s expertise regarding treatment issues for children with emotional and behavioral conditions. We look forward to our ongoing discussions on these critical issues.

In the United States, 1 in 10 children and adolescents suffers from mental disorders severe enough to cause some level of impairment. However, only about one-third of children with a diagnosable mental disorder receive treatment for their problems. Clearly, many children are not being identified or referred for the services they need.

The first step in successfully treating any mental disorder is an accurate diagnosis. Parents, primary care providers and members of the education system need adequate training to understand normal child development and identify children with mental health needs. With adequate training, teachers, school administrators, and primary care physicians can seek help from appropriately trained and credentialed mental health professionals for a thorough evaluation and diagnosis. To ensure access to qualified mental health professionals, the difficulty of obtaining reimbursement for a comprehensive assessment by a qualified professional must be addressed. Other barriers to identifying, recognizing, and referring children with mental health needs include:

• A lack of understanding and consideration of family, ethnic, socio-economic, rural/urban, and gender variables as they impact patient presentation, assessment, treatment, and outcome
• Stigma associated with mental health problems in youth
• Lack of accurate diagnostic tools for ADHD or other mental health dysfunctions for preschool age children
• The demand for qualified mental health professionals outweighs the supply in many areas and the uneven distribution of mental health services across communities
• Lack of health insurance for all children
• Health insurance carriers opting for the least expensive, though not necessarily best treatment options
Primary care providers’ lack of access to appropriate screening and follow-up measures with patients
• Parental stresses such as finances, work or, disability status may limit their ability to recognize their children’s needs
• Lack of parent-training classes

To increase the use of evidence-based strategies, new bridges of communications and new opportunities for collaboration are needed between researchers, parents, providers, and practitioners. To increase the relevance of treatment studies, more research is needed to understand children in diverse "real world" settings, and to measure improvements in symptoms, as well as in functional outcomes such as how children are doing at school, family and peer relationships.

There is also a pressing need for stable institutional resources to support those with relevant expertise in testing promising new interventions, to train newcomers to the field, and to disseminate information about successful intervention models to practitioners in mental health and related professions. It is important to begin teaching about children’s mental health in undergraduate curricula and to integrate studies of these issues throughout all levels of professional preparation for mental health practitioners and other professionals who serve children.

Additional challenges include:

• Building collaboration and communication between basic scientists and clinical and services researchers
• Engagement by the scientific community in research identified as important by parents, families, providers, and practitioners
• Translation of relevant research for parents, primary care providers, and educators
• Financing programs that are empirically supported but are more costly to implement
• Encouraging practitioner to use newer, ore successful approaches rather than treatments they're more comfortable and experienced with
• A lack of ongoing research to evaluate and demonstrate the effectiveness of certain strategies
• Disagreements over which strategy to use when more than one is available

To address the problems of access, several issues must be considered. First, families need to be able to access an expert in child behavior who can make a thorough assessment and diagnosis. Once a correct diagnosis is made, families need access to the best treatment for their child, including psychotherapy and behavioral interventions. While medical interventions have proven effective for some disorders, in many cases the use of pharmacological intervention alone is either inappropriate or inadequate. For these reasons, we believe that the best way to diagnose and treat children is through the integrated collaboration of pediatricians, family physicians, psychologists and other health and mental health professionals, parents, and teachers, according to the training, skills and capacities of each and as indicated by a child’s individual needs. Unfortunately, provisions in many health insurance policies prevent families from taking these steps and often force them to make medication their first, and sometimes only, treatment option. Families need better options in helping their children, including health insurance that covers the full array of services that research has indicated will help their child. Practitioners also need training, not only in delivering services, but also in collaborating with other professionals.

Additional Obstacles include:

• Access; lack of trained professional and services in underserved areas
• Lack of knowledge about available services, transportation to service providers, and language barriers
• Lack of consistency of services from state to state
• Accurate diagnoses of ADHD/other mental health dysfunctions are not yet available for children during the preschool years
• Lack of mental health services and clinics in schools

In addition to addressing the concerns about access to the best treatment, gaps in our knowledge about children’s mental health must be addressed. In particular, more research is needed to assess the long-term effects of medication, behavioral therapies, and their combination, on children. Across almost all disorders, there is a great need for studies on the effects of treatments for girls and for children under the age of six.

While there is a need for more information about specific interventions, there is also a need to understand more about childhood disorders within the context of family, peers, school, home, and community. This will help us see how children with different sets of symptoms and different needs respond to different types of interventions. The development of early preventive interventions for young children at risk of developing later mental and behavioral disorders is another area where more research is greatly needed. Further research is also needed to help us understand more about how effective interventions may be developed and implemented within various health care settings. The National Institutes of Health (NIH) needs additional support to continue to expand research in understanding, treating and preventing children’s mental disorders, and to build a cadre of trained scientists and clinical trials networks to do this crucial research. In addition, prevention services research is sorely under funded.

Additional research and service priorities and needs include:

• Understanding social and cultural influences at the individual level
• Understanding how ethnicity, culture, language, socioeconomic class, family and social networks, and neighborhood or community affect risk, diagnosis, prevention, and treatment
• Long-term effects of behavior therapies and medication on children
• Impact of various treatments on disorders: early intervention; multiple treatments; brief interventions
• More specific techniques to identify ADHD and other mental health problems that go beyond "risk" and determine whether cognitive and/or behavioral interventions can reduce problem behaviors
• Development of more integrated biopsychosocial interventions
• Understanding how policies, incentive structures, and cultures at all levels of health organizations and institutions affect the behavior of those providing care and of those receiving it, as well as the outcomes of care.

Once again, we applaud the Surgeon General’s office and the Administration for coordinating the upcoming conference to draw critical attention to children’s mental health. We hope the conference will involve representative researchers from the biological, psychological and social science fields, as well as clinicians, health services administrators, teachers, and consumers with experience in children’s mental health issues. We would also like to see more emphasis place on primary prevention of mental health problems.

In addition, it is our hope that the conference will highlight some successful programs for young children. Examples include some non-pharmacological, behavioral interventions that have met with success in treating young children with Conduct Disorder (CD) and Oppositional Defiant Disorder (OD). Two examples of such interventions are Parent-Child Interaction Therapy (PCIT), and BASIC. The goals of PCIT is for parents to teach their children prosocial behaviors, and to decrease their child's inappropriate behaviors. PCIT is based on the operant, two-stage model of parent training for noncompliant children developed by C.Hanf (1969). Parents learn to reward consistently their children's positive behavior with attention, and to extinguish negative behavior with ignoring. PCIT is distinctive in that it was designed for use with pre-schoolers; other interventions have been developed with populations that include but are not limited to preschoolers.

BASIC is an example of an intervention for 3 - 8 year olds and their families that uses parental self-management and conflict-resolution techniques. The treatment includes videotape vignettes to teach and model parental skills.

We are aware of a special issue of the Journal of Clinical Child Psychology (Vol 27(2)), June 1998, titled "Empirically supported psychosocial interventions for children." This review of some 82 studies identified 20 that support the efficacy of the two types of interventions described above.

Additional suggestions include:

• Increase federal emphasis on primary prevention of mental health problems
• Organize into modules, each of which works to identify set of recommendations, i.e.:

• Developing community response programs
• Cost effective services
• Training providers
• Responding to preschool children
• Developing a research agenda

• Invite representatives from public education
• Leave sufficient time for discussion; allow for evaluation of goals/outcomes at end of Conference

Many gaps remain in our response to behavioral and emotional disorders in children. It is increasingly clear that the failure to recognize and treat emotional and behavioral disorders in children and adolescents can have devastating results. We know that mental health problems in childhood are related to substance abuse, juvenile delinquency, suicide, and further problems in adulthood. Developing our knowledge base about childhood disorders through investment in research is an investment in the future. Helping children access appropriate, comprehensive mental health services for diagnosis and treatment of child mental disorders is an investment in the life of every child and family who needs help.

Thank you for the opportunity to comment on the planning process for this conference. We look forward to our ongoing discussions about future directions and prospects to increase the health of our Nation’s children.

Sincerely,

L. Michael Honaker, Ph.D.
Deputy Chief Executive Officer

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