| Picture from Yakima County Extension WSU |
"Children are the worlds most valuable resource, and it's best hope for the future." JFK
There is reason for hope, because there are evidence-based practices which help children with emotional and behavioral difficulties and their families to achieve better outcomes than in the past. but there is in fact a very serious lag in implementing these evidence-based practices in real world practice. I share excerpts from study titled, "The Evidence and Science of Medicating Children," by Jacqueline A. Sparks at The University of Rhode Island Kingston, RI and Barry L. Duncan Institute for the Study of Therapeutic Change in Ft. Lauderdale, FL.; published in 2004; and a report from the Policy Lab of the Children's Hospital of Philadelpia Research Institute titled, "Meeting the Mental Health Needs of Children published in the fall of 2010. I used two documents that are six year apart to partially demonstrate the lag I spoke of above, and because of the content one is about the ethics of psychiatric drugs being used to treat children, and the other about the policies which "the system" uses, both offer insight into the problems and potential solutions---the solutions are the reason I have hope.
<!more>The Ethics and Science of Medicating Children
"Our contention is that both common sense and scientific grounding for widespread psychiatric drugging of children is, at best, unconvincing."
"A comprehensive 10-year review revealed a dearth of evidence that either TCAs or SSRIs were effective for children and adolescents (Birmaher, Ryan, Williamson, Brent, & Kaufman, 1996)"
"Client Versus Clinician Ratings of Improvement
In their provocative tour de force, From Placebo to Panacea (1997), Seymour Fisher and Roger Greenberg demonstrate that clinicians and clients differ substantially in their reading of how much improvement has actually occurred. For example, in 1992, Greenberg, Bornstein, Greenberg, and Fisher published an extensive meta-analysis of 22 antidepressant studies involving 2230 persons—and compared the effects of a placebo with both “old” (Elavil, for example) and “new” (Prozac) antidepressants. They found that [both old and new] antidepressants showed an advantage [about 20%] over the placebo on clinician rated measures, but none on client-rated measures. In short, when clients rate their own responses, they often experience no improvement on antidepressants beyond what can be attributed to hope and expectation. If clients don’t feel better after taking medications, how meaningful is any improvement other raters think they see? The Emslie study found no difference between the placebo and SSRI groups on the two client-rated measures. The skepticism researchers have for the perceptions of study participants, even if they are children and adolescents, reflects the mistrust of client views deeply ingrained in mental health discourse. Various explanations have been offered to discount client voices—for example, clients are too impaired by their “illness” to accurately report their condition, or they cannot objectively assess improvement or lack of improvement in the way an observing expert can."
Conflicts of Interest
"Emslie and colleagues completed the Prozac approval sweep in 2002 with the publication of a second placebo-controlled, randomized clinical trial for fluoxetine treatment of child and adolescent depression (2002). The first point of interest is on the first page of this article, which illustrates the fourth fatal flaw of drug studies, namely, who is funding the study and with whom are the authors affiliated."
"In May 2000, the editor of the New England Journal of Medicine called attention to the problem of “ubiquitous and manifold . . . financial associations” authors of drug trials had to the companies whose drugs were being studied (Angell, 2000, p. 1516). Since this Medicating Children time, there has been increasing pressure for medical journals to publicize funding sources and author ties to those sources to alert readers to potential conflicts of interest. It is illustrative to note that in the 1997 Emslie article, no author affiliations to drug companies were noted nor was the study’s funding source identified. However, under the title of the 2002 Emslie study, readers can note that Drs. Emslie and Wagner were paid consultants for Eli Lilly and Company, who funded the research. The remaining six authors were listed as employees of Eli Lilly and “may own stock in that company” (p. 1205)"
The Policy Lab:
E V I D E N C E 'T O 'A C T I O N ' F I N D I N G S
EVIDENCE : Providing prevention-focused intervention for children who exhibit behaviors that are predictof mental health disorders can improve outcomes."
Most children’s mental health problems are left untreated until they reach the severity of a diagnosable disorder. 8 However, children usually exhibit behaviors that are predictive of the development of a disorder well before they receive a diagnosis. 2 Children exhibiting such predictive behaviors are up to five times more likely to develop full mental health disorders than their non-symptomatic peers. 9-11 If these children receive appropriate intervention at an early stage, it can prevent the onset of a diagnosable mental health disorder and improve emotional, behavioral, and cognitive outcomes. ii, 2, 12-18
Additionally, in several studies, the academic, behavioral, and health benefits of prevention focused interventions have lasted more than 10 years after the intervention. 17 "This evidence indicates the need
for a shift towards prevention-focused intervention in children’s mental health.
"The current limited availability of prevention-focused intervention stems partly from the financing structure of children’s mental health services. In most states, providers are required to submit diagnoses from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) to be reimbursed for services provided. "is results in some providers (up to 70 percent) using alternate diagnoses and often inflating the severity of a child’s problems in order to provide or refer to services. When considering using alternate diagnoses, 65 percent of providers surveyed report doing so to obtain services for a patient, and 73 percent report doing so particularly for children with predictive behaviors that do not reach diagnostic severity. 19
This practice is not without potential adverse effects, including the possible stigmatization that results from a child being labeled with a mental health disorder. 20 Furthermore, such labels often serve as pretext for the prescription of psychotropic medications. "This includes the off-label use of atypical antipsychotics, which have been prescribed for children increasingly in recent years despite emerging evidence of adverse effects. 21 Alternately, a provider, knowing the unlikelihood of
reimbursement or the dangers of stigmatization, may delay intervention for a child whose symptoms are not severe enough to warrant a diagnosis. 19 This practice is equally problematic, as children with predictive behaviors are more likely to develop a diagnosable mental health disorder and because timely intervention is very effective among this group. 9-13, 15, 17, 22 In either of these cases, the child with predictive behaviors is unlikely to receive appropriate prevention-focused intervention.
Starting in 2014, PPACA will require all qualified health plans 23 and individual and small group plans 24 to provide a package of essential benefits including mental and behavioral health services. 25 Additionally, PPACA requires that all qualified plans 26 and individual plans 27provide these services at parity with medical benefits. The ongoing process of defining the benefits that will be included in these packages provides great opportunity to reshape the children’s mental health system to better reflect the known benefit of timely prevention-focused intervention. In defining the mental health services included in the essential benefits packages, prevention focused interventions should be prioritized. In the interim—before the full implementation of PPACA—states should mandate reimbursement for prevention-focused interventions to support availability of and access to such services for children. Although Medicaid policy does not generally support intervention for children without a diagnosis, many states have worked within the framework of the current system to expand services to children exhibiting predictive behaviors. 28 As of 2000, North Carolina Medicaid allows six visits annually for mental health services without a diagnosis for children under 21 years of age. These visits can include evaluation and individual or group therapy sessions. 29 Similarly, Washington state passed legislation in 2007 providing up to 20 mental health visits through a fee-for-service network for children who do not meet criteria for a diagnosable disorder. 28 While increased access to these types of clinic treatment is an important step in prevention, states should require public and private insurers to enable mental health professionals to extend a variety of clinic and non-clinic preventive services to children who meet a well-defined set of risk factors.
i In both blending and braiding of funds, the provision of services is supported by multiple systems; however, blending funds combines funds into a single pool while braided funds remain separately linked to the supplying administrative system. ii Effect sizes range from 0.24 to 0.93.
The data used in both of the above documents illuminate some very serious flaws, namely: The ethics violations in both the reporting and conducting of research; and in the provision of mental health care to children and their families. It appears to me that we have in effect been, "sold a bill of goods" by the people we relied on the be honest, ethical and to conduct themselves with integrity. These are not the only players obviously, and the pharmaceutical and managed care/insurance industry has been, equally responsible for the current state of mental health care in the State of Washington, and the Nation.
Changes needed to reverse the trend of using what are known to be ineffective treatments instead of the evidence-based interventions such as psycho-social and cognitive-behavioral treatments; and other types of supportive services that are effective. The other is that Informed Consent needs to become the norm in mental health practice; lack of honesty from professionals about diagnoses and treatment, and not being allowed to make an informed choice, is the chief reason that adults with psychiatric diagnoses and parents like me have lost confidence in and have no trust in mental health providers. The Hippocratic Oath to, "First do no harm..." is not simply an ideal; but a moral imperative; and needs to be the foundation of all mental health services, for everyone. To be considered effective, treatments and services must work first for the children and their families, they must help without causing harm; and they must also be cost effective.
The changes which must be made to achieve these goals are exactly why the the Children's Mental Health Initiative, "CMHI" grants are being given to communities. CMHI, is a part of the Mental Health Transformation a federally funded SAMHSA project is taking taking place in this Country. The Mental Heath Transformation is theoretically being led by the people who are or have been direct recipients of mental health services; and supportive family and community of their choosing. I say theoretically, because it is my opinion based on observation and participation in a local grant project and also from research I have done online for the State-Wide effort that causes me to believe often, the people who should be "at the table often do not even know they should have even been invited, let alone, encouraged and provided the support necessary to become involved. I believe it is due to the human trait of resistance to change, which afflicts individuals and groups of individuals, this resistance is very apparent to me in the mental health and social service providers and government agencies who contract with them to provide services; who are obviously also involved in this Mental Health Transformation.
The reasons for this are not complex at least to me they are not, chiefly, I believe it is due to the fact that most people do not "like" being told that how they do their job needs to change. Then the professionals are told that the first change which will be needed is for them to change their attitude interpersonal relationship with they are endeavoring to help. What I find interesting, is although there is in general an acknowledgement that "the system" is and has been dysfunctional and is not helping the very people it is to serve effectively, the responsibility for this is typically a assigned to the people served or to "the system." The former explanation is ludicrous on it's face, and the latter is as well. "The system" is a bureaucracy made up individuals who are typically in the jobs they have because they are motivated to help others, to serve. It is necessary both for individuals, bureaucratic and social service systems to determine that the idea of helping people is noble and seldom as simple as they once may have ideally thought. If they are disillusioned with what this noble task actually requires, the ethical and the morally courageous thing to do would be to step aside.
I believe this quote sums up an attitude and a perception that must be changed because it is also one of the reasons why the Mental Health Transformation is necessary. It is not the only reason, nor is it the only change required for those who are professionals and affected by and involved with the Mental health Transformation. "The skepticism researchers have for the perceptions of study participants, even if they are children and adolescents, reflects the mistrust of client views deeply ingrained in mental health discourse." This perceptual problem is entrenched not only in researchers; but has become entrenched in mental health and social service providers and the bureaucracies in which they work, and in our society as the result of stigma. We as a society didn't get to this place in time overnight. The CMHI gave out the first grant 25 years ago---before my son was born; which is heartbreaking to me personally.
Obviously the issues are not going to be resolved overnight, but how quickly the changes required will take place depends on ALL of US, and our willingness to learn from the past and a willingness to learn how to make both the personal and professional changes required. I believe it could be happening a whole lot faster---I d not want another child to experience what my son has. It's important for me to remember that my writing and my activism is about the future, not about the past. The CMHI is about those who are children and adolescents NOW---and I believe these children and their families, deserve a better effort to assist them from all of us.
"If my life, and what was done to my son and my family means anything at all, it's meaning for me must be derived from sharing what I have learned and working to keep it from happening to anyone else. I must share what I've learned to hopefully spare another family the same experiences. None of us will ever 'be the same' and life can be bittersweet. My sons and I agree that we need to reach out to others offering hope and whatever assistance we can. I am grateful to know the truth." from About Me.
"Those who cannot remember the past are condemned to repeat it."George Santayana
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