Given that the mental health needs of children play such an integral role in their well-being, and given the tremendous benefits that are likely to accrue from responding to mental health as a primary need, we turn to what is needed for a primary mental health care system for children. A comprehensive primary system of mental health care for children should emphasize appropriate services, ranging from efficacious treatment for those with diagnosed disorders, to early intervention and prevention for those at high risk, to education, consultation, and support for parents and others with mental health concerns about their children. It should also emphasize integrating mental health support and awareness into primary settings for children's development. Implementing and sustaining such a system will require considerable deliberation and significant shifts in current practice and policies. We do not presume that implementing this system is merely a matter of outlining the major components or characteristics of the needed effort. However, we focus here on some basic principles and related characteristics that are essential in the overall system. We refer the reader to the report of the Working Group on Children's Mental Health (Tolan et al., 2001
) for more extensive discussion about an agenda for action for APA and to the report of the President's New Freedom Commission on Mental Health (2003
; Huang et al., 2005
) and the Report of the Surgeon General's Conference on Children's Mental Health
(U.S. Public Health Service, 2000
) for more extensive discussion of legislative and service organization actions.
We suggest four principles that can guide a comprehensive system that simultaneously promotes mental health within normal developmental settings, provides aid for emerging mental health issues for children, targets high-risk youths with prevention, and provides effective treatment for disorders:
- Children and their families should be able to access appropriate and effective mental health services directly.
- Child mental health should be a major component of healthy development promotion and attention in primary care settings such as schools, pediatric care, community programs, and other systems central to child development.
- Efforts should emphasize preventive care for high-risk children and families.
- More attention must be paid to cultural context and cultural competence.
Enhancing Access to Appropriate and Effective Mental Health Services
The first principle for change is that all children who display mental health needs should have access to appropriate professional services. Important components of improving this access include promoting greater recognition of mental health issues among the public and gatekeepers of mental health and shifting the organization of service from provider- or sector-based organization to child- and family-based organization. In addition, as with the other principles, this principle has important implications for the training of psychologists and other mental health professionals.
For children to gain easy access to care, we must overcome the stigma associated with receiving mental health services and the related failure to recognize the importance of mental health. This goal can be achieved, in part, by placing greater emphasis on the importance of mental health and on appropriate and timely responses when training professionals and gatekeepers who work in settings that serve children, including schools, pediatric practices, day care centers, churches, community centers, and community organizations. Professional training should also create an understanding of the role of psychology in typical or competent development as well as signs of psychological maladjustment and the need for mental health care. Training, public information campaigns, and advocacy efforts should also rebut the contention that mental health is something to be considered only after other “essential concerns” are addressed. These efforts should help reduce stigma among both the general public and the gatekeeper community and improve access for youths. Of course, we do not contend that these efforts alone are sufficient to overcome current misconceptions and the underappreciation of the importance of children's mental health.
The Systems-of-Care Approach to Organizing Mental Health Service Delivery
A second important principle in promoting access in primary developmental settings is to follow the systems-of-care approach to organizing child mental health services. This approach can be applied at any needed level to any of the four areas outlined here (Stroul & Friedman, 1996
). The systems-of-care approach evolved in community mental health settings across the country in the 1980s. Systems of care embodies four principles: (a) bringing the treatment to the child and family; (b) including the child and family in all stages of treatment design and planning; (c) “wrapping” services around the child rather than requiring the child to conform to the provider's culture and construal of care; and (d) including all service providers in a unified plan (also see Huang et al., 2005
, and Pumariega & Winters, 2003
, for more detail).
Too often, children's mental health care is delivered in unfriendly and difficult-to-access settings (such as the provider's office). Instead, systems-of-care services can be provided in primary care settings, including pediatric settings and schools, which can increase accessibility for parents and children. Locating services in such settings has the additional benefit of integrating mental health needs and care into the existing child development roles of those settings. Providers also must become more child- and family-centered in their approach to treatment. Too often, a single professional makes a treatment plan based on a diagnosis or specific clinical formulation without considering other systems in the child's and family's life and how those situations may affect care planning. In such cases, if the family objects to the plan or fails to follow it, the professional often concludes that the family was unmotivated or otherwise failed. In a systems-of-care model, family members (and even the child when able) are active partners in formulating the problems or tasks and the actions to be taken. This approach also encourages planning that is developmentally appropriate, culturally competent, and matched to the circumstances of the family.
For example, it makes no sense to organize an intervention for anxiety problems around individual therapy during school hours or in a way that leads to family discord about how and who will bring the child to the session. In addition, it is not beneficial to schedule interventions during times already used for productive activities (e.g., reading or tutoring time, during school, or during sports activities after school). Likewise, prescribing the father's involvement without the mother's consultation (and vice versa) may doom the entire effort. The family's participation in the planning can better ensure their acceptance of the plan and adherence to a treatment regimen. Family-centered and family-collaborative planning can help prevent these impediments to effective care.
Another essential ingredient in the systems-of-care model is the concept of wraparound, in which the services are planned and delivered around the child's needs. This concept differs from approaching each type of treatment as a specific sector. Many treatment programs are funded and planned as if there were “slots” into which children fit. Treatment is provided only when a slot becomes available, at a location that might be far away from the child's home and separated from other settings of care, and from a cultural perspective that may be foreign to the family or child. A better approach is to organize the services so that they are developmentally appropriate, are useful to the family, and incorporate social–ecological factors and other systems in the child's life. Once the provider considers that each child lives within a given ecology, a plan for services and their delivery can be organized or “wrapped around” the child's needs and resources. The likely effect of creating a family- and child-centered approach to services will be greater public acceptance of the concept of mental health services, greater motivation to use assistance among those in need, and more effective approaches with greater effects.
Children's Mental Health Must Be an Integral Component of Primary Care in Health Settings
Including mental health information and services within the existing primary care systems (primarily health care and education) rests on improving several features. A first step is to increase recognition of mental health symptoms and needs as a contributor to other health problems. Hand in hand with this task is the need to increase recognition of the prevalence of mental health issues in situations prompting parental contact with the primary care system, whether for normal pediatric care or for educational planning (Gans et al., 1995
). Second, the repositioning of mental health care could be promoted by increasing service expectations and by ensuring reimbursement for care that addresses mental health concerns or that considers the psychological aspects of health problems (Lasker & Lee, 1994
). For example, an average pediatric outpatient care appointment lasts 7–12 minutes, with the emphasis on minimizing contact beyond efficient diagnosis and treatment of the physical ailment (U.S. Public Health Service, 2000
). This structure minimizes attention to psychological needs. It may also help explain the limited recognition of mental health problems by primary care practitioners (Richardson, Keller, Selby-Harrington, & Parrish, 1996
Another component of making mental health a primary care matter is to increase awareness of, attention to, and expertise in mental health issues among primary health care providers. The effect of doing so will be to provide many parents with brief, helpful direction and to expedite early identification and appropriate care for children with developing problems (Black & Nabors, 2003
A third critical aspect of repositioning mental health care is ensuring that the services delivered are scientifically based. Although scientifically supported interventions have been created and evaluated for numerous childhood disorders, the gap between that evidence and practice is still great. Both researchers and practitioners can take steps to lessen this gap (Levant et al., 2002
; Weisz et al., 2005
). Intervention scientists, for example, have failed to adequately consider the circumstances of service providers and families when designing their interventions. Most interventions have been developed apart from practice conditions, and most have had their efficacy demonstrated using highly trained, closely monitored providers and youths preselected for specific problems. It is unclear whether these characteristics are critical for efficacy, and therefore should become the model for practice, or whether more evaluation of interventions with more typical practice conditions is needed (Kazdin & Weisz, 1998
). However, it does seem clear that evidenced-based programs are preferred over those that are untested or those that have failed to produce significant benefits. Moreover, rapprochement is needed between practitioners and researchers to improve information exchange and influence between the two groups.
Preventive Care for High-Risk Children and Families
At present, little attention is given to universal prevention and indicated intervention for high-risk children, with the exception of a strain of demonstration and research programs. To help parents and others concerned with children showing prodromal symptoms and other risk factors for psychopathology, a shift is needed in how professional advice and short-term services are accessed. The prevailing situation requires evidence of a disorder to access services of a very limited kind. When a child mental health problem does not rise to the level of a diagnosed disorder, the family typically delays services in the hope that the problem is merely transitory, misleading, or not worthy of intervention. Even if recognized, intervention may be elusive given that insurance coverage is unlikely. This practice, although a relatively unchallenged mainstay of child mental health care, is the equivalent of limiting access to health care for cardiac concerns only to those who have documented heart disease with prior life-threatening episodes. This practice policy not only fails to address most of the problems, but it undercuts provider and consumer use of more cost-effective and health-inducing monitoring and interventions. It is analogous to undercutting opportunities for cardiac patients to learn about diet and lifestyle changes or blood pressure medication.
Thus, a major task is to broaden models that emphasize prevention by changing which professional services are reimbursed through health insurance and education funding. Accordingly, mental health professionals must be trained to recognize the need for such services and to provide or refer for such services. Parity in insurance reimbursement is needed not only for mental health treatment but also for mental illness prevention. In turn, when preventive services are available, helping parents, teachers, and others to understand how to access such services, the value of these services, and how best to use them will be important. In addition, a major step in implementing this aspect of a primary mental health care system is systematically making use of evidence-based prevention and early intervention for at-risk populations. In this regard, organizations such as APA could join with other professional and consumer groups to advocate for no longer differentiating mental health needs from other health care needs and for no longer overlooking mental health or underemphasizing it in routine health care and education settings.
Attending to Cultural Context and Influences
Cultural and social status affect child development, attitudes and beliefs about child development, risk processes, and intervention efficacy and utility (U.S. Department of Health and Human Services, 2001
). In addition, disparities exist across racial–ethnic and socioeconomic groups in access to mental health services. However, the solution extends beyond simply changing funding patterns. For example, in many states, through the Children's Health Insurance Program (CHIP) and Medicaid, poor and marginally poor children may have greater access to mental health services than do working-class or middle-class children. It is important to remember that access to effective and appropriate care is inadequate overall. Clearly, funding is not the only cause of disparities by racial–ethnic and socioeconomic status. Disparities can also arise from insensitivity to cultural contexts. Mental health recognition, care, and effects occur within cultural contexts, and therefore mental health promotion, prevention, and treatment should be guided by methods that are “culturally competent” (Pumariega, 2003
), that is, consistent with the cultural characteristics of those involved. An image endures of mental health services as culturally alien to many, as provided to those able to find and come to private offices, and as overreliant on “talk” therapies perceived to be appropriate only for those with the luxury to fret about such extra concerns. Cultural insensitivity and failure to connect the activity to the family's self-determined needs may ultimately impede experiences with mental health issues and services. In short, the field must lessen the misconceptions about interventions and improve their sensitivity to and appropriateness for the cultural and social niche of the child and family.
Although not yet well defined, the concept of cultural competence highlights the importance of understanding the historical, political, and social dynamics of power, the variations in beliefs and practices, and the values about mental health within which services occur. One response to this recognition has been to promote training in cultural competence. However, it is yet unclear what the components of such training should include or what effect it would have on intervention use and outcomes. Such an understanding should have the highest priority in future research.
Important questions remain about whether and how scientifically supported interventions should be shaped to meet the needs of particular cultural groups. An intervention that is effective for one group may or may not be successful with others. When adapting interventions in new settings, local practitioners commonly reshape the program in ways that have intuitive appeal to local citizens. It is unclear, however, whether these changes enhance or hinder targeted outcomes. A major research question is the extent to which group-specific interventions are more effective than interventions applied to all client groups without variation.
Another challenge for the designers of interventions is to articulate which components of an intervention are essential to the theory guiding the program and which can be altered to suit local situations. Further, it is unclear which differentiation of groups and intervention procedures is critical. For example, arguments can be made for more or fewer distinctions between subgroups on the basis of ethnicity, immigrant status, residence, income level, and family makeup. How and when these distinctions are critical has received little empirical attention (U.S. Public Health Service, 2001
). What is clear, however, is that local adaptation will occur. For example, Ennett et al. (2003)
found that school counselors regularly altered evidence-based classroom curricula in substance-use prevention to meet the needs of their students. However, the effects of these variations on student outcomes are unknown. Clearly, more research is needed to understand the importance of adapting interventions on the basis of cultural and social–ecological distinctions, the relative benefits of interventions focused on specific groups, and the balance between universality and specificity in service approach, delivery, and utility.