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Paul Mattessich: Welcome. Welcome to Talking Through The Numbers, a podcast produced by Wilder Research. Our goal is to provide insight on significant issues. We want to combine sound information with expert knowledge so that we can enrich our understanding of things that affect our communities and our world.
I'm Paul Mattessich, Executive Director of Wilder Research, and today our topic is children's mental health. Two experts have come to the studio for this conversation. Dr. Cheryl Holm-Hansen is a senior research manager at Wilder Research. She has a doctorate in psychology and has led studies related to children's mental health for more than 20 years.
Dr. Mark Sander is a senior clinical psychologist for Hennepin County and Director of School Mental Health for Hennepin County and Minneapolis public schools. He has worked in the field of children's mental health for over 20 years. So, thank you for joining us here at Talking Through The Numbers.
To begin, how about some quick definitions to lay the groundwork for the conversation. Our topic today is children's mental health. What do we mean by children's mental health, and conversely, what do we mean by mental illness among children?
Dr. Mark Sander: Sure, I'll start with that. So I think children's mental health in my mind is a pretty broad category. I think oftentimes, people think of mental health as mental illness, which I think is a mistake, as mental illness is only kind of part of it. When we think about mental health, we need to think about mental well-being, positive psychology. Obviously there are issues that come up just like with physical illness, and that's when we think about mental health issues, mental health disorders, and mental illness.
And again, that is just like with a physical illness, there are really effective treatments that we have. It's really important to catch things early.
Paul: Okay, so the labeling is important, you're saying. We should be thinking about mental health, we should think about well-being. There are disorders, there are illnesses. In any given year, if you want to focus on the illness, the disorder part, in any given year, what proportion of children have a mental illness that should be receiving care for that illness ... whether they're getting it or not, what proportion have something that should get some attention or care?
Dr. Cheryl Holm-Hansen: It's an interesting question, because it's hard to tell sometimes. There are not accurate ways of measuring for all people, but the common estimates are that in any given time, about 20% of all children would meet the criteria for a mental health condition ... and that persists through adulthood too, that it's really about 20%.
Paul: Okay, and does that mean a condition that is gonna be with them forever, or it's kind of like you break your arm and it eventually gets better? Or are we talking acute or chronic or…
Cheryl: It combines both. The 20% is at that time, that many people would qualify as having a condition, and what we know is that mental health issues, some can be pretty persistent and be lifelong conditions that people have to manage. Others can be transient. It could be like another kind of medical illness where you have it and you're successfully treated, and then it is not a lifetime-
Paul: Okay, so roughly one in five. Has this gone up or down or stayed the same, and are there any major differences or certain types of children more likely to fall into the category of having an illness or disorder, or what?
Mark: Well, and I'll also look to Cheryl to kind of back me up with more data, but I think there's oftentimes a perception that at any given time, there's more mental illness going on than in a previous decade.
And I think but oftentimes when we look at the data there, it hasn't been a significant increase in actual prevalence. I think it's more about the public's awareness, and also the public's openness to have these conversations, which I think is a really good thing. I think talking about mental health and talking about mental illness is super important to break down that stigma, because we also, in addition to the 20%, we also know that more than half of the adults with mental illness had symptoms before the age of 14.
Paul: Okay, so that's important to understand in terms of lifelong consequences. What about differences? Are poor children, rich children, children of color, white children ... any differences you can see, or are they all kind of even out at about 20%?
Cheryl: Most of the research shows that that 20% rate is pretty consistent across populations. What we know is that there are differences in how many children are identified and treated for mental health issues. That can vary tremendously by background. And within that 20%, there's a huge variety of conditions or challenges that we may be talking about, and there are some variations within that. But the overall 20% seems to be pretty consistent.
Paul: Okay, which might surprise some people that there aren't social differences. This is probably an impossible question, but to the extent you can answer it, what causes mental illness in children, and how do ... We hear a lot about trauma, for example, how does that fit into the causation? Is there anything you can say about the causes of mental illness?
Mark: Well, I think there's a variety of causes, and I think there's ... Certainly, just like with physical illness, there can be people be pre-disposed to anxiety or depression because of genetic factors, heredity, different things kind of going on biologically. But then there's oftentimes a environmental component that maybe is a trigger, and also just kind of developmentally. I mean, sometimes developmentally there'll be challenges that happen in the course of normal development that'll trigger a mental health condition. And then sometimes it can be purely kind of situational. So there's a lot of different factors that can kind of play into the cause of a mental health condition.
Paul: Okay, so it could be genetics, environment, development, situational factors, a variety of things that could come in. You mentioned earlier treatment, and talked about some children have an illness, proportion of those are treated. About what proportion of the children who have a mental illness receive some kind of formal mental health service or treatment for that illness?
Cheryl: The research on that is actually pretty consistent that less than half, for sure, and some studies say it's even lower than that.
Cheryl: But, the most promising studies still peg it at less than half of all children with an identified mental health condition receive formal treatment.
Paul: So doing some quick math, 20% of children have a mental illness at any point in time, half of those receive it, that means about 10% of our children have some type of illness or disorder and are not receiving treatment for it.
Cheryl: Correct, and the studies also show that children of color are half as likely as white children to receive services.
Paul: I was gonna ask you about ... yeah-
Cheryl: So the numbers drop pretty quickly.
Paul: Okay, so cultural or racial groups, with them it's even a lower proportion who are using formal services?
Mark: Yep, absolutely.
Paul: Okay. And why is it that the usage is different for these cultural and racial groups?
Mark: I think there's a variety of factors. I think one of the things is, is that ... is stigma, and kind of the stigma around about mental illness and kind of being able to talk about it.
Paul: And do you have studies that have shown that, or is that more just professional experience, clinicians reporting that about stigma…
Mark: No, I mean I think it was…
Paul: ... or communities themselves saying that to you, or…
Mark: Yeah, I think all of those ... I mean, I think a lot of those things. I think there's a number of studies showing the difference with engagement, and kind of looking at a stigma as a big factor, but then also just hearing about it in the communities. A lot of different communities, for cultural reasons or spiritual reasons, really feel like talking about mental illness is just really kind of taboo.
And then I think another piece is we don't have enough clinicians of color providing the services. So oftentimes, if you're not able to go kind of work with someone who looks like you, who knows your experience, there becomes another barrier to entering into treatment.
Paul: Is anything in the field doing anything about that to get more clinicians of color, or is it nothing happening in that regard, do you know?
Mark: Well, I mean I think there is absolutely a lot of a work around recruitment of clinicians of color. You know, the Minnesota Department of Human Services has had a grant program for a number of years that really focuses on helping clinicians of color kind of move through the process of getting trained and licensed, providing them ... having community agencies provide them supervision and training opportunities to really move along in their professional career.
Cheryl: There's a few other issues that contribute to that disparity that I think are important to note. The ones that Mark mentioned are very important, but there's a few others that come up as well.
One is that the medical model that guides formal mental health treatment isn't always a good fit culturally. There's a strong emphasis on medication and other things that don't always fit culturally. There's also at the societal level issues around how children are identified, and how we interpret their behaviors. And one of the things that we know is that children of color who are exhibiting mental health issues, sometimes those challenges are seen as behavioral challenges, so we see some disproportionate number of children who have mental health issues but are referred for school discipline issues or special education-
Paul: So you're saying-
Cheryl: ... or juvenile justice involvement-
Paul: ... the same behaviors are read, they're interpreted in a different way, and so they lead people down a different path of service?
Cheryl: Correct, correct.
Cheryl: And then we also know that there are challenges with accessing mental health treatment based on poverty, that many of the services are not fully covered by insurance. There may be children who are uninsured or underinsured who have access difficulties, and the times and places where services are available doesn't always fit, that if services are only available during business hours…
Paul: Is that typical? Is it usually just 9:00 to 5:00 Monday through Friday or…
Cheryl: Many of them are. I think many agencies try to accommodate that with evening services or home-based services, but we know that the convenience of service times and locations is a barrier that prevents many children from receiving services.
Paul: So, that's services. What about informal care? What about mutual assistance? What about community support? How does that all fit into the care and treatment of children who have a mental illness?
Mark: So I think, you know, as Cheryl's talking about the cultural factors that we need to be very aware of, I think this is a huge part of where mental health needs to grow, quite frankly. I think that looking-
Paul: Mental health care-
Mark: ... Mental health care needs to grow, is really around acknowledging kind of cultural practices and the healing that can come from that. There's drumming circles in the Native American community. There's a lot of practices that have been around for thousands of years that really have deep meaning for a culture that can be extremely healing and therapeutic, that aren't kind of given enough credence and really are also not given enough funding.
And so, in terms of being able to deliver those types of treatment options, oftentimes there isn't funding, because as Cheryl mentioned, there's such a focus on the medical model.
Paul: Mm-hmm [affirmative], and is this true of all ... Is it true that all cultures have informal ways of providing mutual assistance and support and so forth that are effective? They may be different, but they all have their ways of doing it-
Cheryl: Yes, that's true, and how it looks may be different. But what we know is that these children are in community most of the time, and treatment ... and prevention and treatment of mental health conditions happens in community. It's not a thing that you can just do once a week at your formal mental health program.
So, thinking about where are our children the rest of the time, and Mark certainly can speak to some of the things that are happening in school settings, but thinking about where else are our children. You know, what are we doing through informal programming that children may be involved in, summer programs, recreational programs, faith communities, and in neighborhoods. Children being surrounded by nurturing adults who are looking out for them who are helping to teach social and emotional skills is a strong protective factor for kids, and we have a long way that we could go societally to be really thinking about how we build support around children in ways that maybe compliment the formal mental health treatment, which is really aligned with a more limited set of needs.
Paul: Yeah. So we have a long way to go to do that. What do we know right now about building positive climates for children so that we can promote good mental health? What do we know? We may have a long way to go, but what at least do we know? What base do we have to work on?
Mark: Right, well so we've got 30 plus years of research really showing that positive relationships are extremely important for healthy mental health development and social emotional development. And so I think that is something that everyone can do. It is something that we're talking a lot about in schools. There's a big focus on evidence-based practices related to how people teach math and science and reading, and that's fantastic, but I think in that conversation oftentimes what gets lost is that having a positive, nurturing, caring, welcoming relationship with the child is also an evidence-based practice that can be layered upon lots of other evidence-based teaching practices.
Paul: So what does that mean? So, I'm a dad, I'm a grandad, seven grandchildren, what does it mean for me to have a positive, nurturing relationship that would promote good mental health? Is that complicated, does it take a lot of time, or what?
Mark: I don't think it takes a lot of time at all. I think it's about being predictable, consistent, nurturing, and really engaging ... and it's also about having fun. And so just really being present with that child, and just really spending time with them. I think that consistency is one of the most important things, is just they get comfortable with that and then are allowed to grow and develop-
Paul: Okay, so consistency, engagement, predictability, being present, and overall just having a lot of fun.
Cheryl: Right, and again, we're not talking here about just that being important for the 20% of kids who may be struggling with mental health issues, but that's a strong protective factor for all kids-
Paul: For all-
Cheryl: ... and thinking about how we teach children to relate to each other, how to have relationships, how to address their own feelings of fear or sadness or anxiety, which all children experience. How to handle conflict with each other in healthy and positive ways. Those things are good for all kids across the board, and we can be doing a much better job at that.
Paul: Okay. So Cheryl, for several years, Wilder Research has conducted a statewide study looking at the capacity of our formal service system to meet the needs of children and youth that have mental health conditions. If you're giving your elevator speech, what's the top one or two things we learned from that study?
Cheryl: Yeah, this is a study that we have conducted with the Department of Human Services. It's a report or a project that is funded through the legislature to look at availability and accessibility of services. And what we know is that when we compare children with mental health conditions to other groups across the state, including adults with mental health conditions, children and adult with physical disabilities, older adults, children with mental health conditions have fewer resources available to them. There are shortages in virtually every kind of service, some of-
Paul: In all parts of the state?
Cheryl: In all parts of the state. There are especially pronounced shortages in some of the rural communities, but we know that when we look at the spectrum of services from early intervention and prevention programs up through the programs for children who really have complex and significant mental health conditions, there aren't enough of any of those. And some of the services that come out as being particularly important are those services for kids who have complex, challenging conditions. We know we don't have enough psychiatry, we don't have enough residential treatment, we don't have enough inpatient hospital beds-
Paul: Okay, so there's a lot of-
Cheryl: ... but the shortage-
Paul: ... a lot of shortages, and that probably contributes to that half not receiving services that you mentioned.
Cheryl: It does, and one of the other things that comes out of that study that I find interesting is we interviewed people who have received services or parents of children who have received services, and one of the questions we ask them is how easy or difficult it is for them to receive the services that they need to meet their needs.
And we know that just about half of the parents rated that question as very difficult, that it's very difficult for them to receive the services that their children needs. And in comparison, when we know about the rising number of people who are older and the services that they need, it was 13% of older adults said it was very difficult for them to meet their needs. So there's a huge disparity, even within that social service world, in terms of the accessibility and availability of care for kids.
Paul: So, let me ask a little bit different question about what we ought to do as we move forward. You're experts in the field, what would be one thing that you might recommend we get accomplished to improve children's mental health or to improve the care of children with a mental illness?
Cheryl: I think one of the things that is most important is to think about how we are funding the children's mental health service system. There's a lot that we can be doing for all children in community, but within the formal mental health system, we know some kids need more intensive treatment. They're gonna need community-based treatment, but they also may need mental health therapy, they may need residential care, they may need more intensive supports. And the trend right now is towards less funding for many of those services.
There's challenges in getting those services fully funded through insurance, and some of the other funding streams are coming down right now as well. So we know that we need to preserve the funding and increase the funding so that the money aligns with those services that we know children need at all levels of that mental health spectrum.
Paul: They need and many of which we know are very effective.
Cheryl: They are very effective when they are available to kids, yes.
Paul: Yeah, Mark?
Mark: So yeah, so I think for me, as I talked about earlier, stigma is decreasing, and that's a wonderful thing. I think what's now happening is more and more people are seeing all of these young people struggling with mental health concerns, and they're feeling overwhelmed. And so I think we need to be also continuing our efforts for early intervention.
So, I work a lot in school-based mental health, and getting services into schools is critically important because it really increases access for students and families to get access to care, stay engaged in care, and really get care earlier because we know that treatment works and if we intervene earlier, the odds of treatment being successful rise exponentially. So I think that's a big piece of-
Paul: That has lifelong consequences.
Mark: Yep, so I think it's that balance of we need to be working at both ends of the treatment continuum, really not shying away from having kind of more intensive services for students that need that, but also focusing earlier and really getting in and making care a lot more accessible to families.
Cheryl: And in Minnesota right now, there's a lot that's happening to try to build a more comprehensive network of services for children across that full array, and so it will be fun and interesting to see what emerges out of that work in the next few years.
Paul: Okay. Well, we're gonna need to wrap up, but I have just a couple practical questions for you. So, consider the typical person, a resident of any community in the Minnesota, the United States. If you had to identify something they could do about the issues, a normal person, they don't have a lot of time, but maybe they're willing to do something, what's one practical step they could take?
Mark: So for me, there's a couple of things. One is I think don't be scared. I think oftentimes, people think about mental health conditions, mental illness, and they're like, oh that's somebody ... we need the doctor, we need the psychologist to work with us. Again, it comes back to that idea of just those caring, positive relationships are so impactful, and just trying to help and giving hope is so, so important. So I think that is hugely important.
And then I think the other thing is the mental health system and the children's mental health system is tremendously underfunded, and we just really need additional funding to be able to do the great work that can be done. We know that treatment works, and so being able to deliver treatment earlier to more students and families and children and families is really important.
And then I think lastly, more funding for these kind of cultural approaches to healing is really important.
Paul: Well, you said two things, but you gave three things, and they were all pretty good. So, Cheryl.
Cheryl: Yeah, those were good things, and those overlapped with my things. But I think at the higher level, thinking about how you can advocate for children's mental health. In the funding perspective, by thinking about conversations that we may be having with legislators, that's really important. And we know that locally and nationally more needs to be done to support children's mental health.
And then think about ways that you can get involved with children in your own communities. Or if you are working with children in settings that are not children's mental health settings, learning what's available, learning what children need, finding ways to develop those relationships with children, and just being involved and present.
Paul: Okay, so one very quick final question. You know, I think that to be engaging, to be present with kids and to have a lot of fun, ice cream is always a great idea. So, Mark, what's your favorite ice cream and will you get to eat it this summer?
Mark: My favorite, Pavarotti at ... and I'm blanking on the name of the ice cream shop. But yeah, so I love Pavarotti. It's great, and I definitely will be eating some ice cream this summer.
Paul: All right, Cheryl.
Cheryl: I tend to like the fruity kinds, strawberry, raspberry, things like that. And I will definitely eat some this summer.
Paul: Okay. Well, I hope that we all get to eat our favorite ice cream, and that all children do as well.
Thanks again to our guests, Mark Sander and Cheryl Holm-Hansen. Please visit our website, www.wilderresearch.org for more information on the topic. A lot of studies there you can look at, and also references, links to other sites with similar research and information. If you have suggestions for a future podcast, please let us know. I'm Paul Mattessich from Wilder Research, and I look forward to Talking Through The Numbers with you on other topics.
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