|
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.
Key Barriers to Identifying, Recognizing, or
Referring Children with Mental Health Needs
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
Major Challenges to Using Evidence-Based
Strategies to Identify and Treat Children with Mental Health Problems
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
Major Service Obstacles to Delivering Services
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
Key Research and Service Priorities
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.
Other Suggestions for Organizing the Conference
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
Back to Top^
|