Improving Children's Mental Health: An Updated Agenda and a Roadmap

A significant number of mental disorders have their roots in early childhood and youth. In addition to causing stress and disruption for the child and family, they prevent children from successfully negotiating the normal developmental tasks of childhood, which lead to positive adult functioning. Tasks such as developing social relationships, achieving educational success, developing meaningful relationships with parents and other mentoring adults, developing the self esteem necessary to inform healthful adult choices fall by the wayside when children are burdened with behavioral problems. Such children face isolation and ridicule from their peers, poor services and decreased access to educational support in schools, and disrupted families. Kids who are labeled as problems come to view themselves as inadequate, impaired, and unloved.

It has been shown that resilience can be promoted in some children if they experience a mentoring, nurturing relationship with a consistently present adult.

The immediate and lifelong repercussions of troubled early years are enormous, and are examined in detail in The National Academy of Sciences' recent publication, Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. The book is the first update of a similar document published by the Institute of Medicine in 1994. Research over the past 15 years has underscored the need to focus on young people and on interventions designed to delay or prevent the onset of mental, emotional, and behavioral disorders. Therefore, the authors strongly emphasize prevention, rather than intervention after the fact.

Risk Factors
In order to prevent or avoid mental or emotional difficulties, it is helps first to understand the risk factors, and a great deal of recent research has attempted to pinpoint areas of vulnerability. The following list is not exhaustive, but it gives a sense of the kinds of circumstances that leave children at risk for the development of mental, emotional and behavioral disorders, (MEB):

• Poverty
• Incarcerated, mentally ill or substance−abusing parents
• Physical illness
• Social or cultural isolation within the community
• Maternal depression
• Exposure to violence
• Abuse and neglect
• Foster care

Promoting Resilience
Research has also been looking at the personal characteristics that seem to help protect children during times of hardship and stress. An exciting area of research has been the promotion of resilience. Research has identified resilience, the ability to thrive in the face of extreme adversity, as a key reason why some children develop successfully while others fail. Investigators are now focusing on how to translate those resilience−promoting practices into programs to help children known to be at risk. For example, it has been shown that resilience can be promoted in some children if they experience a mentoring, nurturing relationship with a consistently present adult.

In the 1994 report, the existence of genes that could pass along mental health problems in families was just being recognized. That report called for continued research into this area. Fifteen years later, we recognize that mental health problems involve multiple genes and that the expression of genetic potential for a person to develop a mental illness is influenced by many factors including the family, neighborhood and psychological environments in a child's life. A child's genetic predisposition for mental disorders is affected — both positively and negatively — by the child's interactions with a threatening or nurturing environment. The fact that exposure to stress at certain vulnerable times, or the exposure to conditions promoting resilience at vulnerable times can change the behavioral outcome in a child at genetic risk for mental health has been explored and corroborated in multiple studies in recent years.

Coordinating Treatment
Treating children's mental, emotional and behavioral problems and the family disruption that accompanies and sometimes causes them, involves a multidisciplinary menu of services. Coordinating these services is difficult. Too often, there is a patchwork of reactive services which are fragmented and ineffective because of inefficiencies in sharing information, funding problems, and even differences in the most basic understanding and approach to MEB among service providers. The authors of this new report call for the Departments of Health and Human Services, Education, and Justice to coordinate and align their resources and to encourage their state and local counterparts to do the same. Similarly, as basic research in neuroscience, prevention science, and genetics continue to yield scientific data that can be translated into public policy, the multidisciplinary approach should include these basic scientists as well as the social and behavioral scientists. They recommend that funding priority be given to programs which employ collaboration across institutes and agencies which target similar populations but work with different aspects of their needs.

Policy Issues
There is currently no shared definition of prevention, no National Institute of Health−wide planning or monitoring of programs or spending, and no common research priorities. Most NIH research centers address single disorders such as depression, bipolar disorder, schizophrenia, despite the current knowledge that many MEB problems hold some outcomes in common, share both risk and protective factors, and follow similar developmental pathways. The authors of this new report call on the NIH to develop a 10−year research plan that targets the promotion of mental health and the prevention of MEB disorders that is both cross−disciplinary and multi−institutional. They recommend that funding for programs aimed at reducing risk and strengthening protective factors prior to the onset of disorders, be equal to funding allocated to treatment programs.

The authors note that there are a number of very practical considerations that must be addressed. Populations should not be screened for risk factors if there is no intervention to offer them. Communities must be educated and encouraged to accept programs without fear of negative repercussions or concerns about the stigma of mental health problems. They suggest that there may be a role for the media in such public education. Programs that work should be examined to identify the specific factors that promote success, and these must be viewed in a cultural context when considering what sorts of programs should be implemented with into other community groups. Sensitivity to cultural differences in family structures and communication styles as well as differences in attitudes towards mental health interventions and expectations of children's behavior must be carefully interwoven into program development. Interventions must be based on real evidence which has resulted from carefully designed, scientifically monitored, and rigorously analyzed studies. Our training institutions must develop well−trained investigators and service providers who meet established requirements for certification by completing programs that are reflect evidence− based teaching.

Finally, the characteristics that define healthy functioning of children, adolescents, families, and communities should be identified and expressed as acquirable and measurable competencies much the way early the developmental milestones of walking, talking and socializing have been defined and used as effective tools for screening and measurement. For example, the ability to achieve self−control, the ability to tolerate delayed gratification, the ability to express emotional reactions, the understanding of the role of adult authority figures, and the ability to be empathic with others are all behavioral milestones that childen must achieve to function successfully in society. These behavioral definitions should be used as a yardstick against which needs are assessed and outcomes measured. The authors also call for cost analysis and cost benefits to be included in study designs and recommend incentives for studies that do so. This will help funding agencies decide which programs to implement.

The report evaluates the progress since 1994 and provides a detailed, scientifically−supported roadmap for taking the next steps critical to decreasing the burden of mental health problems on individuals and society. It is a timely wake up call and critically important challenge to federal, state and local government agencies to make much needed changes in our current approach to mental, emotional and behavior problems of children and adolescents.

The report was publicly released on February 13, 2009 and the executive summary can be found on the website of the National Academies Press. The entire 500 plus page document can be purchased through the same website.