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
State Children’s Mental Health Directors
December 8 , 2009
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
Emerging Trends in 2009 Economic
• 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
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
The Global Burden of Mental and
Substance Use Disorders
Figure 1.1. Causes of Disability*
United States, Canada and Western Europe,
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.
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
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
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)
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
Past Year MDE
Receipt of Treatment in
Past Year among Persons
with Past Year MDE
TOTALNot Hispanic or White
African American Native
Asian Two or MoreHispanic or
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)
Did Not Feel
They Needed
Felt They Needed
Treatment and Did
Not Make an Effort
Felt They Needed
Treatment and Did
Make an Effort
21.1 Million Needing But Not Receiving
Treatment for Illicit Drug or Alcohol Use
Beyond the “One child at a time”
• Need for a public health approach
• Factors contributing to the “public’s health”
• Population approach with promotion and prevention
• 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
Burden of Childhood Mental
Emotional Behavioral Disorders
• Most costly and prevalent of all chronic childhood
• Estimates of 20% of children/adol have diagnosable MEB
• 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
Reform of Health Care Sector,
“Necessary but not Sufficient”
• Access and quality alone will not significantly reduce
• 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)
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
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”
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
• Examining policies that are not specifically health
policies that have impact on health outcomes
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
• W.H.O.: invest in early childhood to address health
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
• Anticipate findings starting in 2011
Data Websites
• CDC Website of Child Adolescent Mental Health
Items in CDC Surveys
• Community Health Indicators website
• Child Trends: community and child indicators
• States in Brief – Adolescent Reports (in process)
SAMHSA –States in Brief
• SAMHSA has produced
Individual States-in-Brief
Reports based on 2006
data. Available at:
• More recent data is also
available in online data
tables from the 2007
NSDUH. Available at:
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
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
Obesity Trends Among U.S. Adults
BRFSS, 1985
No Data
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends Among U.S. Adults
BRFSS, 1995
No Data
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends Among U.S. Adults
BRFSS, 2000
No Data
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends Among U.S. Adults
BRFSS, 2006
No Data
Source: Behavioral Risk Factor Surveillance System, CDC.
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
Prevention Intervention Opportunities
(IOM Report, 2009)
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
Prevention of Psychotic Disorders
(W. McFarlane, 2009)
• Early Detection and Intervention
• Data re functioning as effect of number of psychotic
• Effects of untreated initial psychosis
• Reducing incidence of major psychotic episodes in
defined population by early detection and
• Professional and public education
• Inter-professional collaboration
• Incidence effects: 50% reduction in risk
• Cases not converted to psychosis: 77%
• Global assessment functioning in 12 months:
• Formal/informal providers trained in early warning
signs of psychosis
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
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)
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
– Big Brothers/Big Sisters (corporate relationships)
– Congregants as “first responders”
Potential Growth Areas: Community
Health Centers
• 53% CHC located in rural areas (even split
• Frequently only source of primary and preventive
• Serve 1 in 7 of all U.S. rural residents
• 2/3 rural health center patients are uninsured,
• 3/5 are ethnic/racially diverse
• 74% of rural CHCs provide MH counseling on site
• 60% of rural CHCs provide substance abuse
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
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
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.
Early Childhood Systems Federal Partners
Logic Model
Positioning for Health Reform
• Prevention and Wellness
• Comparative Effectiveness Research
• Health Information Technology
Important Prevention Components of
House Bill
• Invest in prevention research to expand evidencebase
• 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
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
• $800M in FY2010 for core public health
infrastructure and activities for state and local health
departments, rising to $1.3B in FY2014
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
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
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
“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
• 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.
“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 disproportionately affects low income women of
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
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
 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
A Two Generation Approach
 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 Pregnant-Postpartum Women in Substance Abuse
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
 Children’s behavior and cognitive performance
 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)
Screening in Substance Use
Treatment Settings
 SAMHSA: 58% of SUD TX Programs screening for mental
health disorders
 Other Studies:
 Among mothers: 83-88% screen positive for depressive
symptoms at treatment entry (Connors, et al., 2006; Lincoln et
al., 2006)
 Among pregnant women with SUD: ~56% have depressive
symptoms (Fitzsimons et al., 2007)
 48% pregnant drug-dependent women in a comprehensive
SUD TX program: have current depressive disorder (Lincoln, et
al., 2006)
 Brief screeners, assessment and Tx urgently needed in SA
treatment and training for frontline staff
 Mood disorders effect drug treatment success (Fitzsimons
et al., 2007)
Prevention Efforts
Individual Approach
• Mothers and Babies Project: 8 week course on strategies to
increase pleasant activities, positive interpersonal relationships, positive
thought patterns to control and manage mood; stress reduction through
relaxation exercises and regular physical activity (pregnant, low-income
• Family Coping Skills Program:
6 group sessions, 2 family
session; skills development (low income Latina mothers)
Two Generational Approach:
• Family CORE: Communication, Openness, Resilience and
Empowerment; focus is to enhance parent-child communication,
knowledge about disorder (single parent families)
Education in Communities re Depression
Early Intervention:
Screening for Depression
• American Academy Obstetrics and Gynecology: rec
psychosocial screening of pregnant women in 1st
– Over the past 2 weeks, have you ever felt down,
depressed, or hopeless?
– Over the past 2 weeks, have you felt little interest
or pleasure in doing things?
• Edinburgh Postnatal Depression Scale: 10 items,
widely used, multiple languages; CES-D
• Screening in WIC Centers. TANF, Community Health
Centers, Employment Centers

A Time of Opportunity: Moving the Agenda Forward for