(p. 633) Conclusion: Successes Since the First Edition and Pressing Issues for the Future of Adolescent Mental and Behavioral Health
(p. 634) Overview
Our concluding chapter of the first edition of Treating and Preventing Adolescent Mental Health Disorders presented a number of pressing concerns about the status of adolescent mental and behavioral health in the United States. In looking back, it is clear that for some of the concerns, progress has been made. As noted by Timothy Walsh in the introduction to this edition, we have greater evidence of the effectiveness of various treatments for adolescents than at the time of the first edition. In addition, the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA) have increased access to healthcare for millions of Americans, including about a third of the population that is under age 26. In particular, healthcare coverage for children through age 25 has been required as part of any health insurance policy. And the MHPAEA has required coverage for mental health and substance use disorder treatment that is comparable to physical health conditions. Greater coordination of pediatric care under the “medical home” model should also enhance access to appropriate health providers (see Chapter 30 in this volume). Initial examination of the effectiveness of greater integration of behavioral health into primary care suggests that this strategy will yield benefits (Asarnow et al., 2015; Kolko, 2015). Whether these changes in access to healthcare services will lead to improvements in population mental and behavioral health in children and adolescents remains to be seen. Nevertheless, these policy changes are no small achievement, and it is difficult to see how they could not improve the health and welfare of children and families in the United States. It is distressing therefore to consider the possibility that many of these advances in healthcare may be abandoned. As this book goes to press, the new administration in Washington is proposing to dismantle the Affordable Care Act. This change in healthcare policy would do considerable damage to the progress that has been made and would threaten the ability to address continued shortfalls in mental health care in the United States.
Despite improvements in the delivery and financial coverage of healthcare, there remain notable deficiencies in the U.S. healthcare system. The first edition noted weaknesses in the major service delivery systems for adolescents, namely the schools and primary care. In particular, neither system has personnel trained to identify, much less treat, major forms of mental and behavioral disorders (Meyers & McLellan, 2005; Romer & McIntosh, 2005a, 2005b). The schools are woefully unequipped to serve this purpose not only due to lack of personnel tasked with this objective but also because training for school staff, even professionals such as counselors, is not directed toward this goal. Similarly, pediatricians and family medicine providers are not trained to recognize or treat common adolescent mental disorders (with the possible exception of attention-deficit/hyperactivity disorder). Finally, there are hardly sufficient numbers of psychiatrists and psychologists trained to treat adolescent mental and behavioral disorders even if they could be correctly identified. Progress has been made in developing resources for improving the identification and treatment of substance use disorders (see Chapter 31 in this volume), and evidence-based practices continue to be disseminated in primary care (see Chapter 30). However, more resources need to be directed toward the training of personnel and medical providers in all of the various services for children (schools, primary care, foster care, juvenile justice) so that adolescents receive the support needed to advance their mental and behavioral health. It is a hopeful sign that the recently signed legislation to improve mental health care in the United States (the 21st Century Cures Act of 2016) will devote resources to the training of more mental health practitioners.
Despite various signs of progress, one of the main conclusions from this edition is the insufficient evidence base on effective treatments for adolescent presentations of the disorders covered in this volume. We find it disconcerting that these gaps remain despite the fact that all of these disorders inflict a heavy toll on adolescents. Although we have considerable evidence regarding treatments for adults, there remain (p. 635) many unanswered questions about how best to treat adolescents. It is hoped that the National Institutes of Health that support research on adolescent mental health will work to overcome these deficits.
Pervasive Effects of Poverty on Parents and Children
Even if we could do a better job of identifying and treating mental disorders in adolescents, the effects of poverty, a major source of poor health outcomes, would continue to affect adolescents. Since the first edition of this volume, poverty levels have increased in children and adults ages 18 to 64 largely due to the financial crisis of 2008 (DeNavas-Walt & Proctor, 2015). The financial status of families has become all the more precarious since that event, with over 20% of children living in poverty. Although suicide rates had been declining at the time of the first edition, following the financial crisis, those rates have increased in adolescents and young adults (Romer & Rich, 2016). In addition, there is some evidence of a recent increase in symptoms of major depression among adolescents (Center for Behavioral Health Statistics and Quality, 2015). Although the reasons for these increases are probably complex, they are coincident with increases in suicide among adults in the parent age range that were evident even before the financial crisis (Curtin et al., 2016). While suicide is only the tip of the iceberg, so to speak, youth with poor mental health are disproportionately located at the bottom of the economic ladder (Reiss, 2013). The effects of financial distress undoubtedly compromise the ability of parents to provide appropriate care, with a multitude of effects on children’s mental health, including greater risk for maltreatment, mood disorders, and externalizing behavior (Choe et al., 2013; Reiss, 2013; Roberts et al., 2009).
One approach introduced since the first edition to reduce the effects of impaired parenting, nurse visitation for first-time mothers living in poverty, has been expanded with additional support from the Affordable Care Act. It is a tribute to the government for expanding this program, which has a substantial evidence base in its support. However, other approaches to ameliorating the effects of poverty are also supported by evidence (AAP Council on Community Pediatrics, 2016; Yoshikawa et al., 2012). For example, the study by Copeland and Costello (2010) of Indian reservations in which poor families received a cash supplement that substantially increased their resources found dramatic improvements in child externalizing behavior that were attributable to better parenting. There are many ways to improve the financial security of families (AAP Council on Community Pediatrics, 2016; Yoshikawa et al., 2012), but evidence suggests that reducing the financial hardship of poverty for families with children is a cost-effective intervention for enhancing child and adolescent health and well-being.
It is disconcerting that the effects of violence in youth continue to dominate national attention. Although rates of death involving gun violence in youth have declined since the peak of the 1990s, rates of youth injury from guns treated in emergency departments have increased (Planty & Truman, 2013), and death by suicide in youth is heavily attributable to the use of guns (Wintemute, 2015). Efforts to reduce exposure to unsecured guns in homes is an important policy objective, and laws that restrict access to guns appear to reduce their use in suicide (Mann & Michel, 2016). Continued pressure to pass such laws will be needed if the United States is ever going to achieve success in reducing the harm from this highly potent means.
At the time of this writing, new legislation to reform mental health care confronts the harmful use of guns by focusing on persons with mental disorders as an important source of the problem. While this strategy may be well intentioned if it helps to reduce the mental health conditions that predispose to suicide, it is unlikely to have much impact on the role of gun violence in assaults and homicides. Those forms of gun violence are much more heavily (p. 636) related to the ill effects of poverty and the ready access to guns in high-poverty locations (Harrell et al., 2014). Nevertheless, reforms that increase the number of providers and other resources for greater access to care represent a welcome development. Continued efforts to reform the juvenile justice system should also be pursued in view of the high rates of mental disorder in the juvenile population that is ensnared in this system (Bushman et al., 2016).
Research on the Genesis and Treatment of Mental Disorders
In the first edition, we noted the need for a national study of youth development that could follow a large cohort of children into and beyond adolescence to identify trajectories of healthy and unhealthy development and potential influences on those outcomes. Although a large children’s health study was eventually abandoned by National Institute of Health, another effort to study brain development in a cohort of 10,000 early adolescents into adulthood (the Adolescent Brain Cognitive Development [ABCD] study) may provide a mechanism to identify such trajectories (Reardon, 2014). Although this study focuses on drug use, it should also provide evidence regarding the development of a wide range of mental and behavioral disorders that are comorbid with drug use and that potentially encourage its use. We look forward to the findings from this ambitious effort and hope that it will shed light on the factors that influence adolescent mental health.
The National Institute of Health has also embarked on a new effort to study mental health conditions that partially abandons reliance on DSM classifications of disorder as the route to discovery. This effort, known as the Research Domain Criteria (RDoC) approach, emphasizes research on more general processes that appear to underlie a wide range of disorders, including negative and positive valence systems, cognitive systems, social processes, and arousal systems. To the extent this approach recognizes the considerable comorbidity that characterizes mental health conditions, it should shed light on the pathogenesis of these disorders. Recent research suggests that just as tests of cognitive ability share considerable variation, the same may be true to some extent of mental disorders (Kim & Eaton, 2015; Lahey et al., 2015). The RDoC approach may help to identify the processes that underlie such general predispositions and advance our understanding of their development.
A National Youth Development Strategy
As outlined in Chapter 19 on substance abuse prevention, the United States does not have a national strategy to enhance the development of youth. Many evidence-based practices sit in repositories but go unused in a concerted fashion. The challenges posed by persistent poverty leave many youth in jeopardy of school failure (Sznitman et al., 2011), which has deleterious effects on the future productivity and health of the population (Muennig, 2015). There is evidence that early intervention, such as nurse visitation and preschool attendance, produces large dividends (Campbell et al., 2014), and many states and localities are moving ahead with these strategies. However, a coordinated strategy of resources to assist families with children from birth to young adulthood should be a national priority.
Most of the developed world has such policies in place (see http://www.youthpolicy.org/nationalyouthpolicies/). A good example is the plan put forth by the government of Australia, which includes objectives for a variety of youth health and education needs and specific programs to advance the objectives (http://www.youthpolicy.org/national/Australia_2010_National_Youth_Strategy.pdf). Some steps toward a coordinated youth development plan for the United States were initiated in 2013 with Pathways for Youth (http://www.youthpolicy.org/national/United_States_2013_Pathways_for_Youth.pdf). The federal government also hosts a website with resources for program planners (youth.gov). We look forward to further progress in that initiative.
(p. 637) Despite the challenges noted, we would like to end on a positive note. In recent years, many indicators of adolescent mental and behavioral health have shown marked improvement. For example, use of many drugs and cigarettes is down, rates of death due to homicide have declined, as have birth rates among adolescents (Romer & Rich, 2016). However, there is little evidence that major forms of adolescent mental health disorders have declined, and thus greater efforts to reduce these conditions are clearly needed. Suicide remains well above the levels of the 1960s, when those rates began to rise, and, as noted above, in recent years those rates have increased. A national agenda that focuses on adolescent mental and behavioral health across the spectrum of disorder would be a welcome addition to our public health priorities. (p. 638)