Perhaps nothing stirs our sensibilities more than a child in need. In today's increasingly complex and turbulent world, children of all ages and from all sectors of the community seem to be in trouble, whether it be truancy, substance abuse, behavior disorders, academic failure or mental illness or distress.
Newspaper articles and editorials about Children's Mental Health often attempt to place the blame for continuing problems on health insurers' reluctance or refusal to support treatment without limitation or controls. Indeed when individuals are less than 18 years of age, all problems from bedwetting to violence are assumed to be caused by internal emotional conflict and, therefore, treatable by our healthcare delivery system, if only there were adequate coverage and compensation.
The realities of children's problems, are far wider and more complex than those described by politicians, advocates and even some providers of care. As with adults who fail to succeed in the mainstream, personalities and behaviors of troubled children are the result of interacting forces and factors that are not easily amenable to influence or change. The result is societal frustration, which is sometimes vented angrily at its representatives. We hear it all the time:
That baby would not have been abused if DCYF had done its job... That juvenile would not have committed suicide if he had not been prescribed Accutane for his acne... That 15 year old girl would not be pregnant if the teacher had not discussed sex in class... That 14 year old boy would not have stolen that car if his health plan covered residential treatment.
The unfortunate truth is that the problems of children, like the problems of adults, are multi-determined and involve, to some varying degree, a decision or choice by the child. It is a convenient excuse on society's part to affix responsibility for troubled behavior on the healthcare system and its inadequacies.
If only recovered we covered residential treatment. If only we paid more for child psychiatry.
It is attractive to think that a relatively simple change in coverage would make such a significant difference. The reality, however, is quite a different matter. By the time that many children experience serious trouble, they have usually been enrolled in a variety of psychotherapeutic treatments, including the prescription of one, or often multiple, psychotropic drugs. But such treatments are only a partial answer, at best, if the troubled behavior is due to socialization that conflicts with the mainstream.
Such dysocialization may be due to a subculture, the absence of effective parenting, or the influence of peers. In other words, the behavior is not an expression of internal, emotional conflict, which would be treatable by psychotherapy, rather, it is a learned behavior, rooted in a value system that is at odds with the larger culture.
For example, if education is not valued, then missing school causes no internal distress. When I was a consultant for a locked, residential facility for adolescents, I remember a young boy who was there on a court-ordered stay due to multiple arrests for stealing car radios. While he clearly knew right from wrong, he was very proud of his ability to steal car radios and record time. Not only did he not consider stealing the radios to be wrong, he derived great self-esteem from it, as his accomplishments were highly valued in his peer group. Rather than causing him emotional distress, which might have been the basis for psychotherapeutic attention, this behavior was entirely consistent with his internal valve system and was acceptable in his social world. Outside of his world, however, there is no debate that a problem exists. But I submit to you that the issue is the nature of problems and the systems that are responsible for addressing them.
Some years ago, a proposed amendments to the RiteCare contact spoke of care managers ensuring that needs for "food and housing" were met. Well there is no question that food and housing are real and imminent needs, there is room for debate as to whether such needs are the responsibilities of health insurance. Similarly, while some of the problems of children are emotional or mental, not all of them are. Behavioral health treatment can make a contribution to the resolution of maladaptive behavior, but cannot bear such responsibility alone.
Residential treatment provides 24 hour-a-day access to the child and offers an environment in which resocialization to other values can be accomplished. Resocialization, though, requires consistency over time-- the average length of stay for success is measured in months and sometimes in years.
The content of such a program is not properly "mental health" but rather a consistent expression of society's values and mores as they are encountered in daily living. While psychotherapy may be a component of such a residential program, it is more of an adjunct than it is a principal activity. To a lesser degree, Children's Intensive Services (CIS) as provided by the Department of Human Services/ Department of Children Youth and Families, has functioned in a similar role-- as a kind of extended family member who tutors the child in the art of coping with everyday life. Again. the issue is not so much the need for the service as it is the nature of the service rendered.
The problems of some troubled children are too complex to be addressed by the healthcare delivery system alone. And no matter how willing, the healthcare delivery system is not adequate to the task. While behavioral health treatment can play a role in addressing these problems, the nature of the problems is such that a more systemic approach is needed for effective change to occur. The unfortunate reality is that many troubled children have received all of the services that the delivery system can offer and yet continue to act in dysfunctional ways.
Greater attention to family systems and to substance abuse would improve outcomes, but cannot, in themselves, provide a total resolution. Those children whose problems are emotional or mental in nature tend to respond positively to services already in place. But for children and adolescents whose problems are more dysocial in nature, behavioral health treatment alone, even without limitation, will not succeed.