By Susan Blumenthal, M.D., M.P.A. and Jean Guo, B.A.
October 5-11 is Mental Illness Awareness Week, a time to mark the importance of mental health to an individual's overall wellbeing. In a national online survey released last month, 90 percent of American adults reported the belief that mental health and physical health were equally essential for their own overall health. This perspective must also be underscored for our nation's youth given the high prevalence of mental disorders among children and adolescents in the United States.
Mental illness affects up to 1 in 5 American youth, and are among the most economically costly conditions to treat in this population. In fact, according to the Centers for Disease Control and Prevention (CDC), the cost of mental disorders including health care, use of services such as special education and juvenile justice, and decreased productivity for those under age 24 in the U.S. is an estimate $247 billion annually. Furthermore, half of lifetime cases of mental disorders begin by age 14 and three quarters of cases by age 24. A mental disorder left untreated is likely to result in the development of other concurrent mental illnesses and substance abuse disorders as well as long-term consequences including poorer performance in school and involvement with the juvenile justice system.
Substance abuse and suicide are other serious and tragic consequences that are linked with mental disorders in American youth. 60-75 percent of young people with substance abuse problems have a co-occurring mental disorder. Suicide is the 3 leading cause of death in young people, ages 15-24, in the United States. According to the U.S. Department of Health and Human Services (HHS), more young Americans in this age group die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza and chronic lung disease combined. Given that 90 percent of those who commit suicide had a mental disorder at the time of their deaths, it is vital that we better understand the risk factors for these conditions in youth so as to detect them early and invest in treatment and other solutions that prevent their health damaging consequences.
At the individual level, genetics and other biological factors contribute to a child's likelihood of developing a mental disorder. A family history of mental illness increases the risk that a child will develop some mental disorders. Gender has an impact as well: boys are more likely to die by suicide and have attention-deficit/hyperactivity disorder (ADHD), behavioral or conduct problems, autism spectrum disorders, anxiety, Tourette syndrome, and substance abuse, whereas girls are more likely to have depression or an alcohol use disorder and attempt suicide. ADHD was the most prevalent current diagnosis among children aged 3-17 years. Researchers are acknowledging more and more how critical external factors including family situations, socioeconomic status, trauma, and physical and social environments influence the mental health of children and teenagers.
Studies have found that nearly 50 percent of children and adolescents in the child welfare system have emotional/behavioral problems, whereas that figure jumps to over 70 percent for youth in the juvenile justice system. Children in military families, aged 11 to 17, reported a higher occurrence of emotional difficulties compared to the general population according to a study conducted by RAND. There are also disparities for racial and ethnic minorities. Poverty is a major risk factor: a report from the Urban Institute found that the prevalence of mental health problems was significantly higher for children and adolescents aged 6-17 living at or below the federal poverty level compared to those whose families had higher income levels.
Yet, for children identified to be at high risk, obtaining access to mental health services has been difficult. Approximately 85 percent of young people with mental disorders in juvenile detention centers reported at least one perceived barrier to mental health services. Hispanic and African American children living in urban areas receive less mental health care compared to their Caucasian peers. Additionally, a recent report by the National Academies of Sciences, Engineering, and Medicine found that many children with mental disorders from low-income families eligible for federal benefits are not receiving them.
A major recommendation of this report calls on pediatricians to inform families about the federal supplemental security income (SSI) program and help them apply for benefits. Given that half of the SSI benefits in 2013 disbursed to 1.3 million children were related to the presence of mental disorders, primary healthcare providers play an important role in ensuring that young people receive the mental health services they so urgently need. Health care professionals should provide their pediatric patients with mental health screenings at every visit to assess cognitive and emotional functioning, testing a child's brain vitals just as they would routinely gather information about other vital signs such as temperature, blood pressure, and pulse.
The importance of early identification and intervention for mental illness cannot be emphasized enough. There is an abundance of research pointing to the effectiveness of early treatment of mental illness in reducing developmental delays and the health damaging complications of these disorders during these critical early years of a child's life. Family members, teachers, school administrators, and health care professionals all have important roles to play in identifying behavioral problems so that children can obtain the help they need in time. Parents would benefit from more education about the signs of behavioral and emotional difficulties in their children and where to seek help. School psychologists can work with parents, teachers and other educators to identify mental health concerns early on to help prevent the damaging impact on the learning and development of their students.
School-based mental health centers and programs can make a significant difference in increasing access to mental health services for students. With staff that includes licensed psychologists, psychiatrists, and social workers, some city-wide programs are providing comprehensive services to better identify and assist students experiencing emotional difficulties that affect their academic performance and relationships with their peers and family. Such programs range from on-site mental health services with counseling and crisis interventions to school-wide screenings by community mental health providers. In addition, other services offered through such initiatives include trainings for teachers and parents to identify and refer at-risk students.
Health Policies to Improve Children's Mental Health
New health policies are having a wide scale impact on the early detection and treatment of mental illness in children and youth. A critical component of reducing the toll of mental illness on individuals and communities is ensuring access to mental health services. In the United States, the Patient Protection and Affordable Care Act of 2010 (ACA) resulted in one of the largest expansions of mental health and substance use disorder treatment in our nation's history, increasing access to services in four fundamental ways: 1) providing health insurance parity for mental illness for 62 million Americans; 2) prohibiting insurance plans from denying coverage to people with pre-existing conditions including mental illness; 3) including coverage for preventive and early detection services including depression screenings; and 4) allowing young people up to the age of 26 to stay on their parent's health insurance.
This past summer, several bi-partisan bills were introduced in Congress focusing on improving access to mental health services. Helping Families in Mental Health Crisis (HR. 2646) would authorize or reauthorize numerous early intervention programs as well as suicide prevention initiatives. It would also would strengthen services provided by community behavioral health clinics, change HIPAA (patient privacy) laws so that family members could gain access to some information about their family members in a mental health crisis, and reorganize the Substance Abuse Mental Health Services Administration (SAMHSA). The Mental Health Awareness and Improvement Act (S. 1893) contains provisions that would reauthorize several important federal programs focused on suicide prevention, mental health awareness in schools, and children's recovery from traumatic events. The legislation would also assess barriers to behavioral health integration and would raise awareness about evidence-based practices for mental health and substance use disorders in older adults.
Another piece of legislation, the Mental Health Reform Act (S. 1945) includes initiatives such as grant programs to promote early intervention for mental disorders in children and adults, increases the mental health workforce, and establish a senior leadership position, an Assistant Secretary of Mental Health and Substance Abuse Disorders within HHS. Additionally, the bill creates a new Mental Health Policy Laboratory within the HHS to fund innovation grants that identify new and effective models of care and demonstration grants to bring effective models to scale for adults and children. The legislation also clarifies circumstances in which HIPAA permits health professionals to communicate information about patients in crisis to family members or other caregivers. The Mental Health and Safe Communities Act (S. 2002) provides additional resources to expand programs with proven effectiveness such as pretrial screening and jail diversion programs, mental health courts and crisis intervention team programs for law enforcement and other first responders. It also proposes to modify the National Instant Criminal Background Check System by clarifying when mental health records should be included in the system and when they should not be. While these pieces of legislation represent important steps forward, none of these bills have yet been passed by the Congress.
In 1999, a Surgeon General's Report was issued on Mental Health that underscored its importance to overall health with a set of recommendations to address mental illness. A special report is now needed focusing on children's mental health given the widespread impact these disorders have on young people in America. Just yesterday, the first ever Surgeon General's Call to Action on Addiction was announced which when issued should help individuals, families, health professionals, law enforcement, and other stakeholders take steps to reduce the toll taken by substance abuse and their co-existence with mental illness in our communities. While other Surgeon General reports have focused on tobacco and underage drinking, this new initiative will examine what is known about the broad range of substances abused including the opioid and prescription drug epidemic that is plaguing communities across the country. Hopefully, just as the first Surgeon General's Report in 1964 warning about the health damaging effects of tobacco use has helped cut smoking rates by more than 50 percent saving many lives since that time, this new report will play a significant role in reducing the toll that substance abuse has on adults and youth across America.
Although societal stigma persists that still considers mental illnesses to be a character flaw or personal failing rather than real disabling illnesses just like diabetes or heart disease, much progress has been made to increase awareness of mental disorders in young people and improve access to effective mental health services in schools and communities. Early identification and intervention is a cornerstone in reducing the long-term complications of mental disorders for children and adolescents during these crucial developmental years. Parents, educators, advocates, pediatricians and other health care professionals as well as policymakers all have important roles to play in enabling our nation's children to realize their full potential as they grow into adults with healthy bodies and healthy minds.
In the 21 century, with one out five American youth affected by mental illness, our country urgently needs a mission to the mind; after all, the brain is the last unchartered territory on earth. A better understanding of this inner space -- the human brain -- and the impact of environmental factors on its development and function in behavior are critical. That's why we must make bold investments in research and apply revolutionary new advances in science, technology, and public health to develop innovative strategies for the prevention and treatment of mental illness that can end needless suffering caused by these disorders in children and adolescents. Additionally, more resources are needed to provide effective mental health services and interventions for substance abuse for youth in the United States. Improving the mental health of young people with evidenced-based public policies must be national priority in the days and years ahead. Youth are 33 percent of the U.S. population but they are 100 percent of our nation's future.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of The Huffington Post. She is a Senior Fellow in Health Policy at New America and a Clinical Professor at Tufts and Georgetown University Schools of Medicine. She is also Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the federal government in the Administrations of four U.S. presidents including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, and as Senior Global Health Advisor in the U.S. Department of Health and Human Services. She also served as a White House advisor on health. She provided pioneering leadership in applying information technology to health, establishing one of the first health websites in the government (womenshealth.gov) and the "Missiles to Mammogram" Initiative that transferred CIA, DOD and NASA imaging technology to improve the early detection of breast and other cancers. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch, Head of the Suicide Research Unit, and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health. She has chaired many national and global commissions and conferences and is the author of many scientific publications. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal was named the Health Leader of the Year by the Commissioned Officers Association and as a Rock Star of Science by the Geoffrey Beene Foundation. She is the recipient of the Dr. Rosalind Franklin Centennial Life in Discovery Award.
Jean Guo, B.A., B.A.H. graduated from Stanford University with degrees in Human Biology and Economics. She is currently a Fulbright Scholar at the Paris School of Economics, working on projects to evaluate the health care of immigrants in France.