Children’s Mental Health: From One Kid ….. to Ten Kids…… to All Kids

1. Children’s Mental Health: From One Kid ….. to Ten Kids…… to All Kids Larke Nahme Huang, Ph.D. Office of the Administrator Substance Abuse and Mental Health Services Administration For State Children’s Mental Health Directors December 8 , 2009

2. Connecting with “New Drivers:” new context, new conversations • The Economic Context and Children • An Unsurmountable Treatment Gap • The Public’s Health • Surveillance and Data-Smart • Interdisciplinary Prevention • Promoting New Partnerships • Positioning for Health Care Reform and Administration Policies • Institute of Medicine Reports

3. Emerging Trends in 2009 Economic Context • Economic setbacks for nation’s children: more likely to live in poverty, less likely to have at last one parent employed year round, more living in inadequate housing • Poverty: 10% of White ; 35% of black and 29% of Hispanic children living in poverty • Slight declines in preterm birth and low birth weight • Slight increase in birthrate among adolescent girls; these babies in homes with less emotional support and cognitive stimulation, less likely to earn high school diploma • Proportion of all births to unmarried women highest ever level recorded

4. Children Hit Hardest with State Budget Cuts (Urban Institute, 2009) • Children’s hospital, pediatricians hardest hit by state cuts • One in four children (22M) – health coverage is Medicaid or Children's Health Insurance Program; turned away at providers, etc. • Reduced reimbursement rates  reduce access • Privately insured affected as hospitals and providers cut staff due to revenue shortfalls • Medicaid: primary payer for children’s mental health • State furloughs; budget shortfalls  impact on children’s services

5. The Global Burden of Mental and Substance Use Disorders Figure 1.1. Causes of Disability*United States, Canada and Western Europe, 2000 • Causes of disability for all ages combined. Measures of disability are based on the number of years of "healthy" life lost with less than full health (i.e., YLD: years lost due to disability) for each incidence of disease, illness, or condition.

6. The Global Burden of Mental and Substance Use Disorders • More than 10% of lost years of healthy life • Over 30% of all years lived with disability • Contributing factors: • Relatively high prevalence • Early onset of mental disorders • Chronic or recurring nature of these disorders • Severity of disability associated with many mental disorders • Low rates of case recognition and lack of access to effective treatment World Health Organization, 2006

7. The Treatment Gap: Importance of partners • In 2006, 23.6 million people aged 12 or older needed treatment for an illicit drug use or alcohol use problem. Of these, only 2.5 million received treatment at a specialty facility. • In 2006, 24.9 million adults (> 18 yrs)reported serious psychological distress, less than half of 10.9 million people (44%) received treatment in the past year. (NSDUH, 2007)

8. Had at Least One Major Depressive Episode (MDE) in Past Year and Receipt of Treatment in the Past Year for Depression among Persons Aged 12 to 17 by Race/Ethnicity: Percentages 2005 (NSDUH)

9. Felt They Needed Treatment and Did Not Make an Effort (625,000) Did Not Feel They Needed Treatment(20,114,000) 95.5% 1.5% Felt They Needed Treatment and Did Make an Effort (314,000) Past Year Perceived Need for and Effort Made to Receive Treatment among Persons Aged 12+ Needing But Not Receiving Specialty Treatment for Illicit Drug or Alcohol Use: 2006 (NSDUH, W. Clark) 21.1 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use 9

10. Beyond the “One child at a time” Approach • Need for a public health approach • Factors contributing to the “public’s health” • Population approach with promotion and prevention component • Prevention is NOT a single intervention • Interventions must be evidence-based • Integrated prevention is based in both the community and the health system • Payment reform is critical

11. Burden of Childhood Mental Emotional Behavioral Disorders • Most costly and prevalent of all chronic childhood illnesses • Estimates of 20% of children/adol have diagnosable MEB disorder • Annual financial costs est. $247 billion by National Research Council, Institute of Medicine, 2009 • Non-financial costs: distress and suffering of youth/family, disruption in families, schooling; burdens on social welfare, education, health care, justice systems • Cumulative effect over lifetime on productivity, quality of life and physical health

12. Reform of Health Care Sector, “Necessary but not Sufficient” • Access and quality alone will not significantly reduce inequities • Health care: • is NOT the primary determinant of health • Treats one person at a time • Often comes too late • ~40% health outcomes attributed to social/behavioral factors; 10% to healthcare delivery system; 40% environment; 15% socioeconomics; 5% genetics (L. Green, 2009) 12

13. A New Health Story • Health in all Policies • Prevention is Primary • New Partnerships Creating programs across four levels of social ecology: individual, relationships, community, society

14. Health in All Policies • Health outcomes often products of decision and policies that are social policies, not necessarily “health” policy. • Alcohol/Beer Tax  child maltreatment • Early Challenge Learning Funds; State Early Childhood Advisory Councils • Public Housing  concentrations of poverty • School Consolidation  youth violence • Land use  schools/asthma; “3rd places”

15. Policy Examples: Alcohol Policies and Child Maltreatment • Study of state alcohol tax policies • Original focus: prevention of underage drinking • Findings: 1% tax increase (~ 5 cents on beer)  significant reduction in substantiated child abuse reports • Examining policies that are not specifically health policies that have impact on health outcomes

16. Early Childhood Policy • Early Learning and Child Development • State Advisory Councils on Early Childhood • Early Learning Challenge Funds • How address mental health within these grants? • What are key state structures to involve • Home Visiting: $124 million in new funding through ACF to offer 55,000 first time parents nurse home visiting • W.H.O.: invest in early childhood to address health disparities

17. Surveillance: Prevalence of Serious Emotional Disorders among Children • SAMHSA collaboration with CDC/National Center for Health Statistics • National Health Interview Survey (NHIS) • birth to elderly; Strengths/Difficulties Questionnaire ages 4-17; annual household survey; state level data • Calibration Study to determine diagnoses of SED for children • Anticipate findings starting in 2011

18. Data Websites • CDC Website of Child Adolescent Mental Health Items in CDC Surveys (www.cdc.gov/nchs/measures_catalog/camh.htm) • Community Health Indicators website (www.communityhealth.hhs.gov/homepage.aspx?j=1 ) • Child Trends: community and child indicators (www.childtrends.org) • States in Brief – Adolescent Reports (in process) (www.samhsa.gov)

19. SAMHSA –States in Brief • SAMHSA has produced Individual States-in-Brief Reports based on 2006 data. Available at: http://www.samhsa.gov/StatesInBrief/ • More recent data is also available in online data tables from the 2007 NSDUH. Available at: http://www.oas.samhsa.gov/statesList.cfm

20. Data Presentation Technologies • Place Matters • Geomapping: capacity to map and track data • Compelling Examples: • National Cancer Institute: cancer clusters • Prevalence of Major Depressive Episodes by Professional Shortage Areas by Census Data • San Francisco: viral loadings (disease severity) as determinant of need for AIDs services – beyond just case counts 20

21. Primary Advantages for Policymakers(J.Holt, CDC 2009) “Access” to data (tangible and cognitive) Gaining insights into spatial relationships – identifying patterns in the data Interpretation – how “my” area compares to neighbors and/or other similar areas Conveying complex information in an effective way to a variety of audiences 21

22. No Data <10% 10%–14% Obesity Trends Among U.S. AdultsBRFSS, 1985 Source: Behavioral Risk Factor Surveillance System, CDC.

23. No Data <10% 10%–14% 15%–19% Obesity Trends Among U.S. AdultsBRFSS, 1995 Source: Behavioral Risk Factor Surveillance System, CDC.

24. No Data <10% 10%–14% 15%–19% ≥20 Obesity Trends Among U.S. AdultsBRFSS, 2000 Source: Behavioral Risk Factor Surveillance System, CDC.

25. No Data <10% 10%–14% 15%–19% 20%–24% 25%–30% ≥30% Obesity Trends Among U.S. AdultsBRFSS, 2006 Source: Behavioral Risk Factor Surveillance System, CDC.

26. Prevention: Untapped Opportunity to Reduce Burden of Disorders on Children • Requires paradigm shift to proactively promote health and prevent disorder • Mental health and physical health inseparable • Successful prevention is inherently interdisciplinary • Coordinated community level systems are needed to support young people • Developmental perspective is essential • Target risk factors that contribute to wide range of disorders

27. Prevention Intervention Opportunities(IOM Report, 2009)

28. Prevention of Child Maltreatment as Public Health Issue • Population-based and At-risk Family Prevention • Positive Parenting Practices: Triple P • Motivational Interviewing + PCIT • Safe Stable Nurturing Relationships Measure • Link with Substance Abuse Treatment Programs • Women and Children SA Programs (SA key precipitant for removal and entry/re-entry to foster care) • Implementation of Triple P in Community Health Centers

29. Prevention of Psychotic Disorders(W. McFarlane, 2009) • Early Detection and Intervention • Data re functioning as effect of number of psychotic episodes • Effects of untreated initial psychosis • Reducing incidence of major psychotic episodes in defined population by early detection and intervention • Professional and public education • Inter-professional collaboration

30. Results • Incidence effects: 50% reduction in risk • Cases not converted to psychosis: 77% • Global assessment functioning in 12 months: improved • Formal/informal providers trained in early warning signs of psychosis

31. Prevention of Suicide: “Sources of Strength”(LoMurray & Wyman, 2009) • Health Promotion Program in High Schools • Student ‘Peer Leaders’ promote 8 protective factors that support resilience • Increase connections with “trusted adults” • Suicide Prevention • Connects students in crisis with adults • Breaks “codes of silence” that prevent students from disclosing suicidal peers • Address risk factors of isolation, low adult bonding, friend attempting suicide; peer norms • 40% reduction in North Dakota youth suicide

32. Landmark Studies re Trauma in Childhood and Adult Chronic Diseases • Emerging evidence of trauma associated with chronic diseases – physical, mental and substance use • Experiences in childhood have impact throughout life…brain, cognitive and behavioral development early in life are strongly linked to an array of important health outcomes…including cardiovascular disease and stroke, hypertension, diabetes, obesity, smoking, drug use, and depression… (2008 RWJ Report) • Adverse Childhood Experiences Study: numbers of ACES in childhood directly linked with chronic diseases (Fellitti, et al) • Example: 0-5 year olds more likely to be present when domestic violence occurs • Greater number of ACES linked with physical, emotional and substance use disorders in adulthood • 8.3M or 11.9% of children live with a substance dependent or abusing parent (SAMHSA, NSDUH, 2009)

33. Optimizing Partnerships • Child Care/Head Start • Community Health Centers (Primary Care) • After school Programs (USDA/Cooperative Extension) • Public Housing Authorities (HUD) • United We Ride (Transportation) • NGO, Private Entities, Faith-based Orgs. • YMCA – 10,000 centers-involved in positive youth development • Big Brothers/Big Sisters (corporate relationships) • Congregants as “first responders”

34. Potential Growth Areas: Community Health Centers • 53% CHC located in rural areas (even split urban/rural) • Frequently only source of primary and preventive services • Serve 1 in 7 of all U.S. rural residents • 2/3 rural health center patients are uninsured, Medicaid • 3/5 are ethnic/racially diverse • 74% of rural CHCs provide MH counseling on site • 60% of rural CHCs provide substance abuse treatment/counseling

35. Integration of Behavioral Health and Primary Care • Funding to build more Community Health Centers and expand services in existing CHCs • SAMHSA: Screening, Brief Interventions and Referrals to Treatment in CHC • CDC: Triple P in CHCs; FOA: more behavioral health screening in primary care settings • Understanding of mental health and substance use disorders as chronic illnesses that start early in youth and need ongoing recovery management

36. Emerging Technologies • Telecare: extensive telephone follow-up: trained care managers (nurse or pharmacist) • Demonstrated improvements in depression when telecare is the primary intervention • Telephone Support: perinatal depression prevention: lower depressed mood among women • Web-based Interventions: CBT effective when provided over internet for depression and anxiety: psychoeducation, interaction, and additional telephone or email contact • Text-messaging – Text4Baby= Health Mothers/Healthy Babies Coalition + Voxiva (provider of mobile health technology) + Johnson & Johnson + Wireless Foundation + federal agencies

37. Even the Feds are Collaborating: “Early Childhood Systems Federal Partners Work Group” • Dept Health and Human Services • ACF: Child Care Bureau, Office of Head Start (Child Abuse Prevention, Home Visiting Child Care Programs, HS/EHS) • CDC: National Center on Birth Defects/Devel Disability and Human Development (Education/awareness, prevention programs) • HRSA/MCHB: Early Childhood Comprehensive Systems Grants • SAMHSA: Prevention (Fetal Alcohol Syndrome, Project LAUNCH) Treatment (Systems of Care, Child Trauma Initiative) • Dept of Justice: OJJDP (Safe Start/ child Protection Program) • Dept of Education: Office of Special Education Programs (IDEA) • Joint Grantee and EC Summit: Aug 2010, Washington, D.C.

38. Early Childhood Systems Federal Partners Logic Model

39. Prevention and Wellness Comparative Effectiveness Research Health Information Technology Positioning for Health Reform

40. Important Prevention Components of House Bill • Invest in prevention research to expand evidence-base • Expand capacity of 2 independent advisory task forces: U.S. Preventive Services Task Force and Task Force on Community Preventive Services for systematic reviews • Eliminate cost-sharing on recommended preventive services delivered by Medicaid, Medicare and Health Insurance Exchange

41. Prevention in House Bill • Establish Prevention and Wellness Trust funded at $2.4B, FY 2010; $3.5B in 2014 • Fund activities of USPSTF (include expert on behavioral services for primary care) • $1.1B for community-based prevention and wellness services • $800M in FY2010 for core public health infrastructure and activities for state and local health departments, rising to $1.3B in FY2014

42. Important Prevention Components of Senate Bill • Mandates national public –private partnership for prevention and health promotion outreach and education campaign • Establish community transformation grants to fund programs that promote individual and community health and prevent chronic diseases, explicitly including mental illness • Both bills include preventive services in essential benefits package

43. Other Provisions in the Bills • Home visitation programs for early childhood • Grant funding for school-based health clinics • SBIRT in primary care settings • Workforce: loan repayment for child and adolescent behavioral health; educate PCP about mental health • Postpartum depression: research and support services

44. 2009 Institute of Medicine (IOM) Reports • Preventing Mental, Emotional, and Behavioral Disorders Among Young People:Progress and Possibilities- February 2009 • Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention -June 10, 2009 www.national-academies.org www.nap.edu

45. “Preventing Mental, Emotional, and Behavioral Disorders Among Young People” • Most mental, emotional, and behavioral disorders have their roots in childhood and youth. • National priorities should include (1) provision of the best available evidence-based prevention interventions to at-risk individuals and (2) the promotion of positive mental, emotional, and behavioral development for all children and youth . • Benefits exceed costs for many preventive interventions, with strongest evidence for this potential savings in early childhood. • A number of specific preventive interventions can modify risk and promote protective factors that are linked to important determinants of mental, emotional, and behavioral health, especially in such areas as family functioning, early childhood experiences, and social skills.

46. “Depression in Parents, Parenting and Children” • 148.8 million parents in the U.S. • 17% parents had major or severe depression in lifetime (Nation Co-morbidity Study-Replication, 2002) • 7% in past year had depression = 7.5M • 15.6M children (<18yrs old) living with adult with major depression • Depression disproportionately affects low income women of color

47. Impact of Maternal Depression on the Children • Associations: • Low birth weight, prematurity, obstetrical complications • Preschool: internalizing problems • Child’s negative relationship with peers • Reduced language ability (key to school success) • Behavioral and academic problems in early schooling • More likely to experience depression in adolescents • Peer difficulties • Consistent Exposure to maternal depression linked to disruptive behavior disorders, higher risk for depression, poor emotional/social competence in school and fewer friends (greater than for bipolar or other maternal health conditions).

48. Parental Depression: Impact on Parenting Two Core Parenting Functions Effected: • Fostering Healthy Relationships • Attachment and early brain development, nurturing vs. harsh parenting; balanced relationship and emotional regulation; • Carrying out the Management Functions of Parenting • Safety guidelines, consistent routines, discipline, feeding, facilitate child’s education and obtain “health home” for well-child and acute health care Maternal history of maltreatment increases women’s risk for depression, substance abuse and domestic violence; puts child at greater risk of maltreatment

49. A Two Generation Approach Barriers • Facilities and providers specialize in either adults or children, not both • Rarely asked if adult with disorder has children in the home • Child service system not equipped to identify parents with substance and mental disorders • Financing of delivery system – based on adult acute care or individual well-child or acute care • Treatment for adult may be prevention for the child • SAMHSA’s Project LAUNCH • SAMHSA’s Pregnant-Postpartum Women in Substance Abuse Treatment

50. Impact of Parenting Interventions • Mothers who are depressed can improve their parenting skills (e.g., warmth in relationship, consistency in interactions with child, instructive and stimulating) • Children’s behavior and cognitive performance improved • Levels of parent depression may not have improved • Key Finding: depressed parents can improve their parenting skills, even while remaining depressed. • (Chazan-Cohen et al, 2007)