WASHINGTON UPDATE:
Surgeon General's Conference on Child Mental Health

Ronald F. Levant, Ed.D., A.B.P.P.

I had the honor of representing APA at the Surgeon General's Conference on Child Mental Health held September 18-19, 2000, in Washington, DC. Joining me as APA representatives were President-Elect Norine Johnson and former President Robert Resnick. In addition there were a large number of APA members in attendance either as presenters, group facilitators, or representatives of other organizations. Hence it would be fair to say that psychology was well represented at this meeting.

Background to the Surgeon General's Conference on Child Mental Health

The Surgeon General's Conference grew out of the March 20, 2000, White House meeting on the mental health of children, called in response to concerns about the drugging of preschool children generated by a well-publicized study published in the Journal of the American Medical Association (Zito, Safer, dosReis, Gardner, Boles, & Lynch, 2000). This study found a dramatic increase in the prescription of psychotropic medications to pre-school aged children between 1991-1995. The Surgeon General's Conference also built on the Clinton Administration's significant accomplishments in the area of mental health, including the first-ever White Conference on Mental Health and the release of the unprecedented Surgeon General's Report on Mental Health last year, both of which were initiated by Tipper Gore, the President's Mental Health Advisor.

The First Lady, Hillary Rodham Clinton, sent a prepared statement to the Surgeon General's Conference on Children's Mental Health, subtitled "Developing a National Action Agenda". Quoting from Mrs. Clinton's statement:
I want to applaud Surgeon General David Satcher for bringing together so many advocates and experts today for the Surgeon General's Conference on Children's Mental Health: Developing a National Action Agenda. The work you are doing today and tomorrow has the potential to bring more health and hope to our nation's children-and more peace of mind to their parents.

Despite the progress already made, we know there are still many questions we must confront. We must ask whether children diagnosed with emotional and behavioral conditions are provided appropriate care in today's health care system. More specifically, are they receiving the full range of services they require? Are these services being managed appropriately? And does insurance cover the types of services necessary to provide optimal care?

We also should look at the concerns that have been raised by physicians, patient advocates, and other experts about the extraordinary increase in marketing expenditures for a whole range of medications, including Ritalin. We need to determine whether such marketing has been constructive in making the public more aware of available treatment options. Moreover, we need to determine the implications of the increased use of these medications in very young populations given the lack of knowledge about their long-term effects.

We need to develop long-term strategies for addressing our children's mental health needs, and your work today and tomorrow will play a large role in marketing that happen. With your input, the Surgeon General will develop recommendations to improve the way we diagnose, treat, and care for the children with emotional disorders.

This week's conference is a very important step, but it is certainly not the last step. I look forward to your recommendations and to working with all of you to ensure that young people get the care they need to have the childhoods and future they deserve.

Planning for the Surgeon General's Conference on Child Mental Health

The purpose of the Surgeon General's Conference on Children's Mental Health was to engage families, professionals, and scientists in a meaningful dialogue about issues involved in identifying, recognizing, and referring children with mental health problems for appropriate, evidence-based treatments or services. In preparation for this conference, input from a broad range of associations, organizations, and individuals was solicited on the issues delineated above. This input was obtained by establishing a special web site on the Surgeon General's home page and through direct mailings to over 500 organizations, associations, or persons across the country. Close to 400 responses were received.

In order to craft, refine, and further develop the agenda, a listening session with the Surgeon General was held on June 26th, 2000. Approximately 50 persons representing attended, in addition to numerous federal representatives. Robert Resnick, Ph.D. attended the listening session as APA's representative. The 6-hour conference was structured into 5 breakout groups, led by a facilitator. Each group was asked to focus on the following four questions:

  1. What are the key barriers to identifying, recognizing, or referring children with mental health needs (e.g. definitional, systems, training, assessment issues, costs, etc.)?
  2. What are the major challenges to using evidence-based strategies to identify and treat children with mental health problems?
  3. What are the major service obstacles to delivering mental health care to children and families?
  4. What are the key research and service priorities in children's mental health?
Each group provided a summary, prioritizing their input. A recorder from each group reported this summary back to the Surgeon General and the entire group and this information was provided to attendees at the 9/18-9/19 conference.

Quoting from the summary of the listening session, some of the over-arching themes identified by participants were:

"There is no mental health equivalent to the federal government's commitment to childhood immunization. Such a commitment is needed in order to reduce stigma, re-direct resources, and re-prioritize children's mental health. Related issues include:
  1. Ensuring screening and early identification of children with key service systems.
  2. Providing adequate and appropriate education and training to front-line providers, including pediatricians, family physicians, teachers and educators, childcare workers, and persons involved in the juvenile justice system.
  3. Educating the public about mental health and illness in children.
  4. Engage families in all aspects of service delivery (i.e., identification, assessment, and services).
  5. Bridging research and clinical practice to ensure the implementation of evidence-based treatments and services.

A fundamental problem identified by participants was the lack of a primary mental health care system for children. The responsibility for children's mental health care is divided up among many systems such as education, pediatrics, juvenile, child welfare/social services, and specialty mental health. These systems lack a financial understructure with which to support the range of services needed by children and families. The lack of health parity is reflected in behavioral health care "carve outs," or health plans that contract for mental health services separately, or exclude such services. Due to cost concerns, agencies may shift responsibilities, so that families are frequently caught in the middle and receive no information or conflicting information as to who can best address the child's needs. Such poor coordination results in inefficient and at times conflicting treatments."

The Surgeon General's Conference on Child Mental Health and its Results

The conference was structured as follows. On the first day there were three panel discussions: 1) Identifying, recognizing and referring children with mental health needs; 2) Health service disparities: Access, quality, and diversity; and 3) State of the evidence on treatments, services, systems of care and financing. The presenters include both scientists and family members/consumers (referred to as "youth"). Several attendees commented that there was a notable lack of practitioners on the panels. Breakout groups began on the first day, and continued for four hours on the second day, beginning with preliminary questions on barriers and opportunities to improved child mental health care, and leading up to recommendations for strengthening and improving federal, state, or local policies and practices in five major areas:
  1. How to increase appropriate recognition of mental health problems and referrals?
  2. How to increase access to treatments or services that are developmentally appropriate (e.g., financial and organizational mechanisms)?
  3. How to support the use of scientifically-grounded prevention and treatment services for children and adolescents with mental health needs (e.g. family engagement, sensitivity to issues of diversity)?
  4. How to promote mental health and prevent risks and antecedents of mental illness?
  5. How to monitor and evaluate the above efforts?

During a working lunch on the second the group facilitators synthesized the responses from all of the breakout groups and prioritized the recommendations into what was termed a "consensus statement", which was reported out at the end of the day plenary session. Following one hour of open comments from the floor, Surgeon General David Satcher made the closing comments. He indicated that he expected his staff to work on the output from the conference and write a report on Children's Mental Health which will be posted on the Surgeon General's website and distributed widely within the next few months.

In terms of the substance of the report as it was reported at the plenary session, barriers and opportunities to improving children's mental health were identified, and then there were two overarching points followed by a set of specific recommendations. To paraphrase the overarching points: 1) The national leadership should adopt and communicate a new vision of children's mental health with promotion of wellness at its center and based in primary care. Every child should have an annual check up for mental health. 2) Develop and utilize evidence-based standards for practice. Develop a consensus list of evidence-based treatments, which should be funded and reimbursed with parity with physical health care.

During the open comments session, I rose to express appreciation to Dr. Satcher for his tremendous leadership in calling together a diverse group of professionals and parents/consumers to address the nation's crisis in child mental health, and for his pioneering work in issuing the first ever Surgeon General's Report on Mental Health (DHHS, 1999). I also made four comments about the overarching points:

  1. Before we can adequately address the problems of identifying children in need of mental heath services at the primary care level, we must acknowledge that we know very little about the development of mental health problems in childhood, about the antecedents, risk factors and early signs. Longitudinal research on the development of psychopathology is urgently needed.
  2. Although it is very important to address the problems of identifying children in need of mental heath services at the primary care level, it is also very important to address the relative lack of qualified mental heath professionals trained to work with children and families who would do the actual treatment of the children once they are identified.
  3. Although developing a consensus list of evidence-based treatments is an admirable goal, we must recognize that we know very little about effective interventions for the full range of mental health problems in children. There is 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. To increase the use of evidence-based strategies, new modes of 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.
  4. Finally, it is also a worthy goal that we utilize evidence-based standards for practice. However, although establishing incentives for this are important, they are not enough. We must recognize that mental health practitioners are too busy to take substantial time away from their practices to learn new treatment techniques. Furthermore, for some of the more complex treatments the traditional weekend CE format is not sufficient. Hence new methods of post-degree training of mental health practitioners are needed. These methods might involve such distance education formats as on-line learning and compressed video. Research into the effectiveness of varying methods post-degree training is also indicated.

As always, I welcome your thoughts on this column. You can most easily contact me via email: Rlevant@aol.com

References

      U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Washington, DC: U.S. Government Printing Office.

      Zito, J. M., Safer, D. J., dosReis, S., Gardner, J. F., Boles, M. & Lynch, F. (2000). Trends in the prescribing of psychotropic medications to preschoolers. Journal of the American Medical Association, 283, 1025-1030.

Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), and a member of the APA Board of Directors (1995-97). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

Reprinted with permission of the author.

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