Opening Minds On Mental Health: New Directions for Change

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Opening Minds On Mental HealthNew Directions
for Change

• Kerim Munir, M.D., MPH, D.Sc.
• The Childrens Hospital Boston
• Harvard Medical School
• April 29, 2009, Istanbul, Turkey

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Main Aims

• To develop early childhood and educational
  environments that promote mental health and
  learning
• To stimulate greater interchange among
  disciplines and sectors
• To integrate (1) child education and child
  development with the (2) mental health policies
  with the public health agenda
• To stimulate and disseminate scientifically
  informed national initiatives for moving forward

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Overarching Aims

• Build capacity in schools
• Enhance communication with families
• Promote mental health of staff
• Provide early preventive interventions
• Address stressful social contexts
• Prevent alienation, bullying, and exclusion
• Provide continuum of child care family, school,
  and community
• Build long-term foundation for child development
  and mental health

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Questions

• Why should early education and schools be
  involved in mental health?
• Why should the focus be on mental health and not
  illness?
• Should programs target all or select risk-groups?

• Who should be responsible for planning,
  implementation, and evaluation?
• What are the advantages of an integrated
  approach?

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U.S. Surgeon General ReportNational Action
Agenda for Childrens Mental Health

• Increasing number of children are sufferingtheir
  emotional, behavioral, and developmental needs
  are not being met by the institutions and systems
  created to care for them
• A major player in the de facto system of care is
  the education sector for many children this
  simply may be the only source of care

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U.S. Surgeon General ReportNational Action
Agenda for Childrens Mental Health

• Fewer than 1 in 5 children who need services
  receive treatment (cf., Turkey)
• Vulnerable children less likely to receive
  treatment
• Services are fragmented
• Front line workers need further education
• There is need for collaboration across systems
• There is a need for evidence-based treatments
• Satcher, D.,A Report of the Surgeon General's
  Conference on Childrens Mental Health A
  National Action Agenda, 2001
• Satcher, D. Mental Health A report of the
  Surgeon General U.S. Dept of Health and Human
  Services,SAMHSA,CMHS,NIH, NIMH, 1999

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U.S. Children Receiving Mental Health Services
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Why is Mental Health Important in Early
Educational Settings?

• Mental and physical health are equally necessary
  for optimal child development and learning
• Access to children and families facilitated
• Problems can be addressed early
• Inclusion and equity orientations for developing
  children enhanced
• Societal economic benefits outweigh costs

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Scientific RationaleBrains Skills are Built
Over Time

• Early years matter interactive influences of
  early experience gene expression affect
  architecture of the maturing brain
• Quality of this brain architecture establishes
  either a strong or a fragile foundation for
  learning, behavior, and health
• Nurturing interactions build healthy brain
  circuits
• Persistent toxic stress impair development of
  healthy neural circuits

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Convergence for National and Global agendas
Start Early, Increase Scope

• New generation of leadership needed worldwide to
  address inequalities in opportunity, beginning in
  earliest years of life
• This is not only a moral imperative but a
  critical investment in foundations of a nations
  social and economic future
• Need for education contexts to address
  developmental and psychosocial concerns in
  earliest years

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Embedding Mental Health Challenges

• Current emphasis is on instructional practice
• Mental health is not seen as directly related to
  achieving optimal performance
• Mental health is not seen as a key for reducing
  achievement gaps, drop-out rates, and economic
  disparities

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We cant solve problems by using the same kind
of thinking we used when we created them.

• Albert Einstein

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There is a need for Critical Shift in Thinking

• Mental health is not mental illness or targeted
  services for at-risk few
• This approach is piecemeal, fragmented and not
  cost-effective
• A unifying strategy needed to link children,
  families, schools, and community agencies
• Rethink the complementary (not mutually
  exclusive) ethical balance between individual and
  shared responsibilities for well-being of children

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Developing Initiatives in Early Education
Settings

• Legislation to establish centers to support early
  childhood development and school mental health
• To enhance the role educational sector play in
  public mental health
• To increase the capacity of policy makers,
  administrators, schools, primary health care
  personnel, and other stakeholders in mental
  health issues
• To develop mental health promotion and prevention
  initiatives

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Its mental health not mental disorder,
stupid!

• Its the economy stupid (Bill Clinton, 1991)
• In a study of inner-city schools over 50 of
  children had behavior, emotional and learning
  problems, not diagnosable disorders
• In a study of 188 children under age 3 in child
  protection, 66 had developmental delays
• In a survey of 119 preschool teachers, 39
  reported expelling at least one child from their
  program in the preceding year

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A New Policy Framework

• To enhance understanding of the developing minds
  of children in a social context
• To reduce misdiagnosis and inappropriate labeling
• To re-define mental health to include improved
  social development and learning
• To focus on optimal learning in an inclusive
  environment
• To enhance adaptive functioning

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Defining Mental Health asPositive Concept

• Definitions State of well being and capability
  to function in the face of adverse and changing
  circumstances
• WHO (2001) State of well-being in which the
  individual realizes his or her abilities, can
  cope with the normal stresses of life, can work
  productively and fruitfully, and is able to make
  a contribution to his or her community

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Opening Minds A New Vision of Mental Health

• Ability to experience a range of emotions, e.g.,
  joy, connectedness, sadness, anger, in
  appropriate and constructive ways positive
  self-esteem, respect for others and sense of
  security and trust in themselves and the world
• Function in developmentally appropriate ways in
  contexts of self, family, peers, school, and
  community on a foundation of personal interaction
  and support, initiate and maintain meaningful
  relationships (love) and learn to function
  productively in the world (work)

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Beware Diverse Agendas Come into Conflict

• Different stakeholders pursue conflicting agendas
• Limited resources compete destructively Zero
  Sum Game Survival of the Fittest
• Priorities change High visibility events, e.g.,
  suicide, abuse, bullying, campus violence,
  bullying, aftermath of disasters

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Beware Marginalization

• Existing mental health programs do not have a
  primary status in child development, educational
  hierarchy, public health policy
• Mental health services only gain stature during
  crises and emergencies often short lived (with
  some exceptions)
• Marginalization, not inclusion, becomes the rule
  rather than the exception e.g., children with
  special needs
• Plants seeds for intolerance and stigma

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Beware Limited Solutions for Complex Problems

• Need a stepwise strategy evidence-based pilot
  and demonstration projects
• Over focus on specific problems reduce efforts to
  create integrated care systems
• As budgets tighten costs become a renewed concern
• Complex problems overlap and categorical
  approaches produce limited solutions

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Out of Sight, Out of MindReferral is not
everything

• When a student in school is not doing well,
  tendency is to refer out
• Reduces ownership of risks
• Shifts responsibility as well as costs to
  specialty services
• Causes impossible wait lists
• Delays early preventive interventions
• Problems return and recur cyclically

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Hole in the Mental Health Bucket

• As an old Harry Belafonte song goes
• LISA There is hole in my bucket Dear Henry,
  Dear Henry
• HENRY ell fix it Dear Lisa, Dear Lisa, fix
  it
• LISA With what shall I fix it, Dear Henry, Dear
  Henry...
• HENRY With a straw
• LISA With what shall I cut it
• HENRY With an axe...
• LISA The axe is not sharp
• HENRY Well, sharpen it
• LISA With what shall I sharpen it...
• HENRY With water
• LISA With what shall I fetch it
• HENRY With a bucket
• LISA But, there is a hole in my bucket

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How close are we to having a Coordinated Approach?

• Students with multiple problems have several
  professionals working independently, some have
  none
• Poor recognition that complex problems that
  paradoxically require specialist care also need
  coordinated approaches
• Available efforts cannot maintained over time
• Poor understanding that complex problems risk
  marginalization
• The answer, sadly, is no.

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Where are we withPolicy Leadership?

• To date there has been no comprehensive mapping
  and no overall analysis of the amount of
  resources used for efforts relevant to mental
  health in schools or of how they are expended
• Without such a big picture, policy-makers and
  practitioners lack information essential to
  determining equity and enhancing system
  effectiveness cf., lack of overall analysis of
  mental health relevant expenditures in health
  care systems

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Where are we withDelivery Formats?

• Broad access to quality preschool (3-5) and
  proactive enrollment
• School-based support services
• School-district based health units
• Formal connections with community mental health
  services
• Classroom-based curriculum and out of classroom
  interventions
• Integrated education and primary care sector
  approaches

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Can we wait for interventions to be Empirically
Supported?

• In surveys school staff report a need for
  information about evidence-based practices
• It is important to find where the interventions
  fit within the schools improvement efforts
• The genius is adding evidence-based practices and
  addressing barriers to teaching and learning
  (implementation)

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Implementation Steps Diffusion, Adaptation,
Leadership for System Change

• Implementation of new approaches in schools
  involves diffusion within the organizational
  culture and infrastructure
• The innovative practice needs to be successfully
  adapted at a particular demo site with
  replication-to-scale
• Leadership needs to understand and accept the
  need for systematic change at larger scale for
  such change to occur.

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Are we ready for making aCommitment for Change?

• Process of change is not straight-forward or
  linear
• There are multiple political, bureaucratic
  difficulties in eliciting institutional change,
  especially with limited financial resources
• There is a need for high level of commitment,
  relentless effort, and realistic time-tables
• In recent years advocacy is helping in improving
  select autism services (a key has been relentless
  pressure to develop political will)

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Can we change reliance on Social Control?

• In dealing with difficult behaviors and creating
  safe environments, the degree schools rely on
  social control is an issue
• Need to move beyond punishment and social control
  strategies
• Need for social skills training, positive
  behavior support, greater home/parental
  involvement
• Improving engagement in learning

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Can we adopt a broader Classification Framework?

• The DSM and ICD are currently the dominant
  classification systems for disorders
• Dimensions for psychosocial stress and adaptive
  functioning are contributory, not primary factors
• Pathological framework underscores the need for
  clinical interventions
• Establish best care practice, reduce misuse of
  diagnostic labels, limited waste of resources

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Can we develop a seamlessIntervention Continuum?

• These include mental health promotion, primary
  prevention, secondary prevention, tertiary
  prevention and treatment services
• Coordinated care referral, triage, guidance,
  case management, family services, special
  education, follow-up support, and not only
  referral to select specialty care centers

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Can we adopt medication use within Multimodal
Strategies?

• Need to understand heterogeneity of response to
  medications
• Advanced studies to underscore multimodal
  (combination) treatment approaches
• Limit conflicts of interests for a new era in
  appropriate and more cost-effective use of
  medications

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Developing the Evidence-Base Multimodal
Treatments

• Example NIMH Treatment of Adolescent Depression
  Study (TADS)

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Adolescent Depression

• Prevalence 8.3
• Females/Males 2 1
• Only 1/3 of teenagers receive treatment
• 70 with single major depressive episode will
  have recurrence within 5 yrs
• 20 bipolar subjects have onset during
  adolescence
• Risk factor for suicide, substance use, school
  failure

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Treatment for Adolescents with Depression Study
(TADS)

• NIMH-funded nationwide clinical trial
• 439 adolescents with major depression
• Ages 12-17
• 13 centers
• Randomized double blind

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Treatment Protocols

• Group 1 Fluoxetine only
• Group 2 CBT Fluoxetine
• Group 3 Cognitive Behavioral Therapy (CBT) only
• Group 4 Placebo

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Outcomes

• 71 improved on fluoxetine CBT
• 60.0 on fluoxetine alone
• 43.2 for CBT alone
• 34.8 with placebo

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Recommendations

• Adolescent depression is prevalent
• High morbidity and mortality
• Teens must be identified
• Teens must be treated
• Medication must be available
• CBT should be available

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Obstacles

• Lack of defined psychological and behavioral
  interventions
• Lack of communication between prescribing
  physician and therapist
• Poor or no systematic behavioral data collection
• Poorly justified or inappropriate choice of
  medications

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NAMI Task Force Report

• In treatment of serious disorders children must
  have access to evidenced based multimodal
  treatments
• Policymakers need to enable access
• Families and communities must be educated
• NIMH should increase funding for child and
  adolescent research

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Final Comments

• Commitment for an inclusive new vision of mental
  health encompassing early child development,
  behavior, and learning
• Collaboration between education and public health
  sectors for child, school, family, community
  services
• Equity considerations in cost, access, needs
• Advocacy against marginalization and exclusion
  (tolerant, open society)
• Coordinated care, prevention of competition for
  limited resources, sectors
• Multimodal and evidence-based quality and
  culturally appropriate interventions

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• THANK YOU!

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• NEVER FORGET THE RACE FOR BRIGHTER HEALTHY
  FUTURES CANNOT BE WON WITHOUT MENTAL HEALTH...WE
  NEED YOUR HELP!!