Mental Health Services and Children

It is estimated that the percentage of children and adolescents in the United States who are in need of mental health services is between 15 and 20 percent. This means that more than 10 million children in the country suffer from some mental disorder. It is also estimated that 3 to 8 percent have a serious mental illness. More children suffer from psychiatric illness than from leukemia, diabetes, and AIDS combined. There are also both short-term and long-term financial and emotional costs associated with these disorders.

Determining which children need mental health services is a complex undertaking. In most cases, a youth has to receive a mental health diagnosis from a qualified clinician. The American Psychiatric Association, in their Diagnostic and Statistical Manual (DSM), has codified diagnostic categories. Researchers may use a structured clinical interview, such as the Diagnostic Interview Schedule for Children (DISC), to obtain a diagnosis, but these rigorous instruments are rarely used in clinical practice, and there is little agreement among clinicians in their use as a diagnostic tool. In addition to meeting the criteria for a diagnosis, federal regulations now require that for a child to be classified as having a serious emotional disturbance (SED) the child must have a functional impairment in two or more areas. These areas include home, school, and work (where relevant).

Who Receives Mental Health Services?

Children can receive mental health services from several sources, including schools; mental health institutions such as hospitals; community mental health centers; mental health services provided through child welfare; services from juvenile justice; and primary care physicians. Estimates of use of mental health services by children range from 1.9 to 6 percent in any given year for the general population. Most children receive services from schools.

There are several factors that are related to an increase in the probability in accessing mental health services. In two studies comparing a system of care that offered a full range of services with the more typical community services, such as those provided by community mental health centers, children were more likely to receive services, and to receive more services, in a system of care. (A system of care includes a continuum of services from outpatient to hospitalization, coordination or management of these services, and, usually, the involvement of multiple child-serving agencies.) However, the provision of services in a system of care was more expensive and was not any more effective than the usual services available in the community.

Use of Services

Patterns of service use are not well understood, but it is generally agreed that services are underutilized by youth. There are several possible reasons for this, including the stigma associated with such services and parental dissatisfaction with services. Most children do not enter services willingly, and it should be recognized that specialized children's mental health services alone will never be sufficient to meet the need for mental health services. More services will have to be provided by other systems, such as schools and the juvenile justice system.

There is a high dropout rate of children from services, although estimates vary considerably. Some studies have found that 40 to 60 percent of children who begin treatment terminate it before the therapist recommends they should terminate. It is believed that the majority of children attend outpatient treatment for only one or two sessions. It is not clear why the dropout rate is so high, but it is suspected that referral to services are often made by others, such as schools, and not the parent or adolescent.

Where Do Children Receive Mental Health Services?

School systems. Schools usually identify children with mental health problems only after the problems have not been successfully dealt with by their classroom teacher or their parents. However, once identified, students are much more likely to use the services in the schools than in the community. Schools usually try informal interventions before referring a child to special education. A federal law, the Individuals with Disabilities Education Act (IDEA), requires that such children be evaluated and, if eligible, placed in a special classroom or provided with special assistance in their regular classrooms.

There is a strong relationship between SED and several measures of school performance. Students with SED have lower grades, are retained more often in grade, and fail more courses than other students with disabilities. Less than half (42%) of children with SED graduate high school, as compared to 56 percent of students with other disabilities and 71 percent of all students. The rates of identification of youth with SED vary across racial, gender, and socioeconomic lines, with Hispanics and Asian Americans receiving proportionally the least amount of services. Research also suggests that students from low socioeconomic backgrounds and males are overrepresented among those identified with SED.

Schools are not good at identifying children with mental health problems. There are several reasons for this difficulty, including the avoidance of stigma, lack of training in recognizing mental health problems, and the desire of the system to avoid the costs of mental health services. There is not a substantial amount of evidence that schools are successful in treating children with mental health problems. Comprehensive support systems and training for teachers and administrators are not typically found in school systems.

Recent trends in SED lead to one of three possibilities: (1) the number of children with SED is increasing, (2) schools are recognizing more children with SED, or (3) both of these are occurring. Since 1976 there has been an increase of more than 118,000 students with SED (a 48% increase) receiving services under the Chapter 1 Handicapped program of the Elementary and Secondary Education Act (ESEA) and IDEA Part B programs. However, this program ended in 1994.

As in other service sectors, there are a significant number of children who are not receiving needed services in the schools. In addition, little is known about the quality, appropriateness, or effectiveness of the services delivered to children and adolescents in schools.

Primary care. Pediatricians and primary-care physicians prescribe most of the psychotropic drugs prescribed for children. They may also counsel families, but some studies indicate that families do not interpret this counseling as mental health services. For preschool children such visits may be their only contact with a health delivery system. Studies have shown that physicians often fail to identify children with mental health problems. Moreover, parents often fail to mention that their child has a problem. There are several barriers to proper identification and the delivery of effective services–physicians are not trained to deal with mental health problems, the service may not be reimbursed at an attractive level, and the average visit to the doctor is only eleven to fifteen minutes long.

Juvenile justice. The magnitude of mental-health-service needs far exceeds current resources in the juvenile justice system. It also appears that children of low socioeconomic status populate the juvenile justice system, and thus are less likely to receive mental health services because they are in the juvenile justice system. Findings show that mental health placements are rarely used relative to other court outcomes (i.e., dismissal, probation, or other types of placements), and that gender and race significantly influence whether a child will receive a mental health service. Females are more likely to receive mental health services than males, and white delinquents are more likely to be placed in a mental health setting than black offenders, regardless of gender.

The Effectiveness of Mental Health Services

Providing ineffective services to children and adolescents would clearly not be good public policy. It would simply waste resources and not result in any improvement in child outcomes. Moreover, it would provide the illusion that society is intervening in a positive manner and thus inhibit change. For this reason, determining the effectiveness of services is a key goal in this field. A distinction should be made between the efficacy of an intervention and its effectiveness. Efficacy studies examine a treatment under optimal situations. These studies are likely to take place in a university-based laboratory using well-trained and supervised clinicians and children who are selected to meet the needs of the study. For example, a study of the treatment of depression would screen out all children who had depression and other comorbid mental health disorders; only children with depression alone would be studied.

Standing in stark contrast to efficacy research, effectiveness studies evaluate the effects of treatment in typical conditions. Studies of effectiveness are conducted in community mental health centers and in real-world settings such as schools. In these studies the investigator does not have the same level of influence on which types of children get into the study, how the therapists are trained and supervised, and how carefully they follow the treatment approach. The distinction between efficacy and effectiveness is important because each type of study tells a different story about how beneficial mental health services for children and adolescents are.

Although efficacy research is important in establishing the potential utility of treatments, these studies are not very informative about how the intervention will operate in the real world. While there are hundreds of efficacy studies of psychological child and adult treatments, there are only a handful of effectiveness studies. Meta-analytic studies of treatment (mostly psychotherapy) show that, on average, mental health treatment is very powerful when studied under laboratory-like conditions. However, the picture is different for effectiveness studies.

Most effectiveness research has been done on such system-level constructs as service coordination and access. There have been few studies of the child and family outcomes of mental health treatment. These studies have not found that treatment makes a difference in child and family outcomes. For example, the Fort Bragg Evaluation Project, the largest study of mental health systems of care, found that children in a system of care had increased access to services compared to children receiving treatment as usual in the comparison sites. However, both groups improved over time and the clinical and family outcomes did not differ between the two groups. Unfortunately, the system of care was much more expensive and thus could not be justified. Research in this area is in its infancy; only more research in the real world will lead to an understanding of the conditions under which mental health treatment is effective.

The contrast in findings between efficacy and effectiveness studies is dramatic. It is suspected that a major reason for the weak effects found in the community is that practitioners are not using effective treatments. To encourage the use of effective treatments, several professional groups are identifying what they describe as evidence-based treatments. These treatments typically have sufficient efficacy results to warrant their use. Some organizations, such as the American Pediatric Association and the American Academy of Adolescent and Child Psychiatry, have developed diagnosis and treatment guidelines that are less specific than evidence-based treatments that are spelled out in treatment manuals. However, just informing practitioners about the existence of evidence-based treatments is not sufficient for practitioners to adopt those practices. It is not clear that these techniques can be transferred to the real world, or that practitioners will use them. It is also uncertain if the guidelines are specific enough to make a difference in outcomes.

There are several reasons why these efficacious treatments are not being used in clinical practice. First, there is no agency in the behavioral field similar to the Food and Drug Administration that certifies medications as safe and effective. This means that there is no central authority that approves the several hundred existing behavioral treatments. There are few advantages for the already overworked clinicians to make significant changes in their practices and to incur the costs of additional training in evidence-based treatments. New research is focusing on how to encourage service providers to use new treatments.

Medication

Progress has been made in the use of medication to treat several disorders, including attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), and childhood anxiety disorders. In addition, studies are underway to test the effectiveness of medication for major depression. Clinical trials are also being started for bipolar disorder, autism, and several other mental disorders.

A major study on ADHD found that medication was more effective than behavior therapy for symptom reduction. However, combining medication and behavior therapy was more effective for children who had co-occurring disorders such as anxiety and ADHD. Furthermore, this study found that medication was more effective when managed by the study investigators than when medication was managed by physicians in routine community care. The investigators think that the greater effectiveness under the more controlled conditions was related to the higher frequency of office visits, their longer duration, and the more carefully controlled dosage.

One of the problems in using medications for the treatment of mental disorders in children is that the Food and Drug Administration (FDA) has not specifically approved most psychotropic drugs for use with children. While it is legal and ethical to use medications tested on adults on children, this "off-label" use means that physicians do not have research findings to guide their treatment decisions for the majority of psychiatric problems. An additional problem with medication treatment is that many severely ill children are treated with multiple drugs simultaneously. There are no systematic studies of the effects of polypharmacy, and thus the effects of combinations of medications are not known.