The Child-Adolescent Mental Health Services (CAMHS) system confronts clinically complex youth with high rates of behavior problems, diverse mental health disorders, substance abuse, criminal behavior, and other “at risk” behaviors (e.g. school truancy, family conflict, etc.). Because of the complexity of the youth, the system has serious difficulties helping them to successfully overcome the myriad of problems they confront. This group proposes that a public health approach would help solve many of the inadequacies of the current system.
Public health has been variously defined; however, all definitions recognize it as the art and science of dealing with the protection and improvement of community health by organized community efforts. As such, it includes prevention, screening, and treatment, as well as environmental and social interventions. We propose that a public health approach should be taken on behalf of child mental health. Although public health is often conceptualized as focusing on physical health, we take the holistic position that “there is no health without mental health.”
A public health approach is appropriate because the strengths and problems of children and adolescents are based upon interactions between their internal genetic/biological predispositions, as well as their family, community, school, and societal environments. Through research, we are uncovering more and more evidence that all aspects of environment (intra-person, family, peer, community, and even society) are important:
- We can document the importance of the social and physical environment as a determinant of behavior and mental illnesses (Rutter 2006; McDonald and Murray 2000);
- The link between environment and human development is well-known (Leventhal and Brooks-Gunn 2003; Stiffman et al. 1999; Sampson et al. 1997);
- We have evidence that when a child or adolescent’s environment is improved, some mental health problems decline (Costello et al. 2003; McKay 2005; Stiffman et al. 2007); and
- There is evidence that even the most resilient of children will succumb to a chronically stressful environment (Vanderbilt-Adriance and Shaw 2006).
A public health approach would provide an over-arching framework to integrate all arenas (health, education, social services, child welfare, juvenile justice, mental health) for interventions and services. First, it should be comprehensive in involving and integrating the arenas where the children are, rather than being confined to only the mental health arena. Second, the public health approach should be comprehensive in its scope and ideally range from health promotion through disease prevention to disease treatment. Third, the approach should be comprehensive in terms of the population and diseases targeted, including universal as well as intensive foci.
A public health approach requires an ecological understanding of mental health and mental illness. Thus, potential targets for such an approach range from the most proximal issues concerning the individual, to the more distal, starting with the family, moving outward to the community (neighborhood, housing, etc.), and finally to the sociopolitical environment which includes public policy and economics. Each of these layers of ecological features suggests different forms of interventions, and each layer confronts the reality of finite resources, opportunity costs, and social processes. At the same time each of these ecological layers suggest potential leverage points for solving issues concerning child and adolescent mental health services.
The potential of the public health approach to address the limitations of the mental health model for children and adolescents has been recognized by others. In 1961, the Joint Commission on Mental Illness and Health issued its call for mental health system transformation (Joint Commission on Mental Illness and Health 1961). This commission noted the rising demand for mental health services and recommended that public health professionals become more knowledgeable about the prevalence and spread of mental health disorders. The Surgeon General in 1999 also called for a public health approach to the outreach, prevention, screening and treatment of mental health disorders for all, and especially for populations of color. More recently, Kathryn Power, in her capacity as director of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (SAMHSA), advocated for the development of a public health model of mental health that takes a community approach to prevention, treatment, and promotion of well-being. Two states that are recipients of Mental Health Transformation Grants from SAMHSA (Texas and Washington) have made the public health approach a core feature in their transformation (Crump 2007; Ganju 2008). Similar support for this integrative approach is also seen in the advocacy community (Blueprint for a Healthier America: Modernizing the Federal Public Health System to Focus on Prevention and Preparedness 2008; Guiding Principles for Collaboration between Mental Health and Public Health 2005; Bazelon Center for Mental Health Law 2005).
Clearly, there is a widespread recognition of the importance of a public health model as a solution to the limitations of the current CAMHS. The remainder of this paper details potential barriers to optimal child and adolescent mental health services, and suggests potential public health oriented solutions to those barriers.
The primary barriers in mental health services are finite resources, limited policy perspectives, disjointed systems, a lack of a comprehensive multi-tiered approach, inequity in access, and failure to adopt effective interventions.