Developing a Continuum of Care: A Necessity for Child and Adolescent Mental Health Treatment

By Dr. Jennifer Katzenstein, Director of Psychology & Neuropsychology, Johns Hopkins Children’s Hospital, St Petersburg, Florida, U.S.

Children around the world increasingly are being diagnosed with mental health disorders. Depression is the single leading cause of disability worldwide, according to the World Health Organization (WHO), and data from the Centers for Disease Control and Prevention (CDC) suggest that one in five children in the U.S. between the ages of three and 16 have a diagnosable mental, emotional or behavioural health disorder. Suicide is the 10th leading cause of death in the U.S. at an annual cost of $69 billion, and rates are on the rise.

The increase in suicide is observed worldwide, with a global rate of 10.7 per 100,000 in 2015. Despite recognition of increases in mental healthcare needs, in the U.S., only approximately 20 per cent of children and adolescents will be diagnosed and receive care. With suicide rates higher than ever before, it is our responsibility, as healthcare providers and healthcare systems, to develop mental health programmes for our communities.

In 2013, the WHO enacted a comprehensive mental health action plan, with primary objectives including strengthening leadership and governance for mental health, providing a comprehensive, integrated and responsive mental healthcare system across settings, implementing strategies for promotion and prevention, and strengthening evidence and research focused on mental health. This action plan is aspirational, even in 2019, with continuing barriers to mental healthcare limiting progress.

A lack of well-trained providers across the continuum who understand evidence-based practices limits mental health services for children and adolescents in need. Continued evidence shows cognitive behavioural therapy treatments and psychotropic medications, in combination, are the most effective treatment for many mental health diagnoses. Daily barriers, including reduced reimbursement for services, few resources, and limited time and space, leave practitioners few opportunities to focus on a comprehensive approach to services that includes prevention, early intervention and specialised care.

To expand access and develop prevention programmes, primary care providers have taken on a greater role in mental healthcare. However, primary care providers continue to be undertrained in mental health diagnosis and treatment. Residency curriculum and primary care mental health programmes are increasing attention on mental health, which results in increased empowerment of primary care providers to work to prevent mental health concerns.

However, schools and educators play a large role in prevention as well, with an additional need for mental health focused curriculum needed for educators, administrators and school nurses. Schools are increasingly focusing on positive behavioural, emotional and social support, and these programmes are necessary for establishing pro-social behaviours.

Identifying Risks

Early intervention and screening have the opportunity to reduce costs by avoiding more specialised treatments in the future and educate children and parents on warning signs that will allow for earlier diagnosis. Maternal mental health and general health plays a large role, as this early relationship sets the stage for future self-regulation and emotional development. Identification of those most at risk, such as those who have experienced childhood maltreatment (including exposure to violence and other traumatic events), discrimination, bullying, malnutrition and other stressful events, allows for appropriate early intervention and the potential for improvements in mental wellbeing. Early identification of children and families at risk for mental health diagnosis is likely to significantly reduce the number of children diagnosed later.

Hospital systems find themselves underprepared for increasing rates of mental health concerns. Children and adolescents are presenting more frequently to emergency centres with mental health and psychiatric concerns, and the emergency centre physicians and care teams often have very limited training in mental health and limited resources to address these concerns. Children’s hospitals in the U.S. are beginning to open psychiatric emergency centres, with an opportunity to address concerns rapidly and urgently. Yet, these sites remain limited, and necessitate the full continuum of mental healthcare, including inpatient, residential, intensive day treatment and outpatient services, which have limited access. Evidence-based intervention by highly trained and qualified specialists remains a key barrier and, at the same time, a necessity for access to appropriate mental health services for children and adolescents.

Despite increasing focus on mental health diagnosis and treatment worldwide, the full continuum of mental health interventions remains limited. A well-trained, specialised and fairly compensated mental health provider workforce remains a primary barrier. Specialised treatment modalities, including psychotherapy, psychological testing, medication management and family education are key to providing an appropriate continuum of care. As interventions intensify, high quality residential treatment facilities are key, as well as therapeutic homes for more severe mental health concerns. While most children and adolescents will not require this level of care, worldwide systems remain underprepared for the increasing complexity of mental health presentations in children and adolescents. With an ever-increasing need for mental health services, and an ongoing need for an appropriately trained and specialised workforce, in high acuity health care settings, we remain underprepared worldwide to meet these needs.

More than ever before, individuals are sharing their mental health diagnoses and stories. This reduction in stigma assists with parents and adolescents seeking care when needed; however, additional education on early signs, symptoms, and appropriate treatment is necessary to improve overall outcomes and improve quality of life. Capacity to identify and treat those in need necessitates collaboration across multiple systems and individuals. Healthcare providers, both primary care and specialist, must be prepared to work with systems that are typically separate, including schools, government agencies and communities. For healthcare systems, this may mean cross-system communication, sharing of information, and multi-tier treatment systems that cross-cut multiple systems and environments for each child’s daily life. This comprehensive level of care may be what it takes to address, and in turn, decrease, mental health diagnoses in children and adolescents.

Early identification and appropriate treatment for child and adolescent mental health concerns is necessary to prevent later adult mental health disorders. Approximately one-half of all adult mental health disorders are diagnosed before age 14, and early diagnosis and treatment is necessary for prevention of life-long mental health conditions that can result in disability, under-education and unemployment.

Long-term, systematic change will require intensive time and training. Future goals for development of mental health treatment programmes must include a family-focused approach, by a well-trained workforce that spans the treatment continuum, close to the family’s home. Healthcare providers and hospital systems must take initiative in development of innovative strategies for prevention, early intervention and specialised care. Increased focus worldwide on mental health must be a primary objective for the future in order to ensure the overall health and wellbeing of future generations.