Children’s Mental Health Care: A Surprisingly Steady Evolution

Abstract

Having been involved in the public policy process for some period of time, we are constantly amazed by how long substantive change can take and also by the resistance that seemingly well meaning and highly educated colleagues consistently demonstrate (Pachter and DeLeon 2007). From a health policy or, as several of the conference authors have urged, ‘‘public health’’ perspective, the status of children’s mental health services in our nation leaves considerable room for improvement. Many, if not all, of the authors have concluded that today the delivery of mental health care to children and adolescents is simply not of the highest quality, nor is it even acceptable, especially given how much money has been expended over a considerable period of time. Will the Obama Administration’s Health Care Reform proposals finally make a difference? We are definitely optimistic. From a broader perspective, it is critically important that those involved in the delivery of mental health come to appreciate that the challenges of the future for those interested in children’s mental health are fundamentally the same as those facing other colleagues serving within the more generic health care arena. Specifically: How does one measure and then insist upon the systematic delivery of data-based, individual patient-centered quality care? The Institute of Medicine (IOM), since its establishment in 1970, has served as an independent health policy advisor to the Congress and various Administrations. The IOM has reported that: ‘‘The American health care delivery system is in need of fundamental change.... Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge. Yet there is strong evidence that this frequently is not the case’’ (IOM 2001a, p. 1). Further, that: ‘‘The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15–20 years. Even then, adherence of clinical practice to the evidence is highly uneven’’ (IOM 2001a, p. 155). And, perhaps most unsettling, that: ‘‘Between 30 and 40 cents of every dollar spent on health care is spent on the costs of poor quality. This is an extraordinary number representing slightly more than about a half trillion dollars a year’’ (IOM 2002, p. 67). We received our clinical training during the era of the community mental health centers movement, which emphasized the role of social factors in mental health and the importance of mental health to the health of our society. The reality is that health, behavior, and societal influences are inextricably intertwined (IOM 2001b). Mental health care today is but one component of our nation’s health care delivery system. As such, it is unfortunate that many of our training institutions have not provided their students with an understanding of the larger health care environment. The health care system as a whole has considerable room for improvement and mental health care is not necessarily less scientifically driven than is, for example, cancer care. From this perspective, it is unreasonable to expect (or be professionally frustrated) that any one element would be more advanced than another. Historically, many mental health professionals have attempted to function in a clinical vacuum, as if the mind and body were separate. Yet, the President of the IOM has noted: ‘‘(I)mproving our nation’s general health and quality problems of our general health care system depends upon equally attending to the quality problems in health care for mental and substance-use conditions.... Dealing equally with health care for mental, substance-use, and general health conditions requires a P. H. DeLeon (&) W. S. Pachter 5701 Wilson Lane, Bethesda, MD 20817, USA e-mail: patdeleon@verizon.net