Surgeon General's Conference on Child Mental Health
Ronald F. Levant, Ed.D., A.B.P.P.
I had the honor of representing APA at the Surgeon General's Conference
on Child Mental Health held September 18-19, 2000, in Washington, DC. Joining
me as APA representatives were President-Elect Norine Johnson and former
President Robert Resnick. In addition there were a large number of APA
members in attendance either as presenters, group facilitators, or
representatives of other organizations. Hence it would be fair to say that
psychology was well represented at this meeting.
Background to the Surgeon General's Conference on Child Mental Health
The Surgeon General's Conference grew out of the March 20, 2000, White
House meeting on the mental health of children, called in response to
concerns about the drugging of preschool children generated by a
well-publicized study published in the Journal of the American Medical
Association (Zito, Safer, dosReis, Gardner, Boles, & Lynch, 2000). This study
found a dramatic increase in the prescription of psychotropic medications to
pre-school aged children between 1991-1995. The Surgeon General's Conference
also built on the Clinton Administration's significant accomplishments in the
area of mental health, including the first-ever White Conference on Mental
Health and the release of the unprecedented Surgeon General's Report on
Mental Health last year, both of which were initiated by Tipper Gore, the
President's Mental Health Advisor.
The First Lady, Hillary Rodham Clinton, sent a prepared statement to the
Surgeon General's Conference on Children's Mental Health, subtitled
"Developing a National Action Agenda". Quoting from Mrs. Clinton's statement:
I want to applaud Surgeon General David Satcher for bringing together so
many advocates and experts today for the Surgeon General's Conference on
Children's Mental Health: Developing a National Action Agenda. The work you
are doing today and tomorrow has the potential to bring more health and hope
to our nation's children-and more peace of mind to their parents.
Despite the progress already made, we know there are still many questions
we must confront. We must ask whether children diagnosed with emotional and
behavioral conditions are provided appropriate care in today's health care
system. More specifically, are they receiving the full range of services
they require? Are these services being managed appropriately? And does
insurance cover the types of services necessary to provide optimal care?
We also should look at the concerns that have been raised by physicians,
patient advocates, and other experts about the extraordinary increase in
marketing expenditures for a whole range of medications, including Ritalin.
We need to determine whether such marketing has been constructive in making
the public more aware of available treatment options. Moreover, we need to
determine the implications of the increased use of these medications in very
young populations given the lack of knowledge about their long-term effects.
We need to develop long-term strategies for addressing our children's
mental health needs, and your work today and tomorrow will play a large role
in marketing that happen. With your input, the Surgeon General will develop
recommendations to improve the way we diagnose, treat, and care for the
children with emotional disorders.
This week's conference is a very important step, but it is certainly not
the last step. I look forward to your recommendations and to working with
all of you to ensure that young people get the care they need to have the
childhoods and future they deserve.
Planning for the Surgeon General's Conference on Child Mental Health
The purpose of the Surgeon General's Conference on Children's Mental
Health was to engage families, professionals, and scientists in a meaningful
dialogue about issues involved in identifying, recognizing, and referring
children with mental health problems for appropriate, evidence-based
treatments or services. In preparation for this conference, input from a
broad range of associations, organizations, and individuals was solicited on
the issues delineated above. This input was obtained by establishing a
special web site on the Surgeon General's home page and through direct
mailings to over 500 organizations, associations, or persons across the
country. Close to 400 responses were received.
In order to craft, refine, and further develop the agenda, a listening
session with the Surgeon General was held on June 26th, 2000. Approximately
50 persons representing attended, in addition to numerous federal
representatives. Robert Resnick, Ph.D. attended the listening session as
APA's representative. The 6-hour conference was structured into 5 breakout
groups, led by a facilitator. Each group was asked to focus on the following
Each group provided a summary, prioritizing their input. A recorder from
each group reported this summary back to the Surgeon General and the entire
group and this information was provided to attendees at the 9/18-9/19
Quoting from the summary of the listening session, some of the
over-arching themes identified by participants were:
"There is no mental health equivalent to the federal government's
commitment to childhood immunization. Such a commitment is needed in order
to reduce stigma, re-direct resources, and re-prioritize children's mental
health. Related issues include:
- What are the key barriers to identifying, recognizing, or referring
children with mental health needs (e.g. definitional, systems, training,
assessment issues, costs, etc.)?
- What are the major challenges to using evidence-based strategies to
identify and treat children with mental health problems?
- What are the major service obstacles to delivering mental health care to
children and families?
- What are the key research and service priorities in children's mental
A fundamental problem identified by participants was the lack of a
primary mental health care system for children. The responsibility for
children's mental health care is divided up among many systems such as
education, pediatrics, juvenile, child welfare/social services, and specialty
mental health. These systems lack a financial understructure with which to
support the range of services needed by children and families. The lack of
health parity is reflected in behavioral health care "carve outs," or health
plans that contract for mental health services separately, or exclude such
services. Due to cost concerns, agencies may shift responsibilities, so that
families are frequently caught in the middle and receive no information or
conflicting information as to who can best address the child's needs. Such
poor coordination results in inefficient and at times conflicting
The Surgeon General's Conference on Child Mental Health and its Results
The conference was structured as follows. On the first day there were
three panel discussions: 1) Identifying, recognizing and referring children
with mental health needs; 2) Health service disparities: Access, quality, and
diversity; and 3) State of the evidence on treatments, services, systems of
care and financing. The presenters include both scientists and family
members/consumers (referred to as "youth"). Several attendees commented that
there was a notable lack of practitioners on the panels. Breakout groups
began on the first day, and continued for four hours on the second day,
beginning with preliminary questions on barriers and opportunities to
improved child mental health care, and leading up to recommendations for
strengthening and improving federal, state, or local policies and practices
in five major areas:
- Ensuring screening and early identification of children with key service
- Providing adequate and appropriate education and training to front-line
providers, including pediatricians, family physicians, teachers and
educators, childcare workers, and persons involved in the juvenile justice
- Educating the public about mental health and illness in children.
- Engage families in all aspects of service delivery (i.e., identification,
assessment, and services).
- Bridging research and clinical practice to ensure the implementation of
evidence-based treatments and services.
During a working lunch on the second the group facilitators synthesized
the responses from all of the breakout groups and prioritized the
recommendations into what was termed a "consensus statement", which was
reported out at the end of the day plenary session. Following one hour of
open comments from the floor, Surgeon General David Satcher made the closing
comments. He indicated that he expected his staff to work on the output from
the conference and write a report on Children's Mental Health which will be
posted on the Surgeon General's website and distributed widely within the
next few months.
In terms of the substance of the report as it was reported at the
plenary session, barriers and opportunities to improving children's mental
health were identified, and then there were two overarching points followed
by a set of specific recommendations. To paraphrase the overarching points:
1) The national leadership should adopt and communicate a new vision of
children's mental health with promotion of wellness at its center and based
in primary care. Every child should have an annual check up for mental
health. 2) Develop and utilize evidence-based standards for practice. Develop
a consensus list of evidence-based treatments, which should be funded and
reimbursed with parity with physical health care.
During the open comments session, I rose to express appreciation to
Dr. Satcher for his tremendous leadership in calling together a diverse group
of professionals and parents/consumers to address the nation's crisis in
child mental health, and for his pioneering work in issuing the first ever
Surgeon General's Report on Mental Health (DHHS, 1999). I also made four
comments about the overarching points:
- How to increase appropriate recognition of mental health problems and
- How to increase access to treatments or services that are
developmentally appropriate (e.g., financial and organizational mechanisms)?
- How to support the use of scientifically-grounded prevention and
treatment services for children and adolescents with mental health needs
(e.g. family engagement, sensitivity to issues of diversity)?
- How to promote mental health and prevent risks and antecedents of
- How to monitor and evaluate the above efforts?
As always, I welcome your thoughts on this column. You can most easily
contact me via email: Rlevant@aol.com
U.S. Department of Health and Human Services. (1999). Mental Health: A
Report of the Surgeon General. Washington, DC: U.S. Government Printing
Zito, J. M., Safer, D. J., dosReis, S., Gardner, J. F., Boles, M. &
Lynch, F. (2000). Trends in the prescribing of psychotropic medications to
preschoolers. Journal of the American Medical Association, 283, 1025-1030.
- Before we can adequately address the problems of identifying children in
need of mental heath services at the primary care level, we must acknowledge
that we know very little about the development of mental health problems in
childhood, about the antecedents, risk factors and early signs. Longitudinal
research on the development of psychopathology is urgently needed.
- Although it is very important to address the problems of identifying
children in need of mental heath services at the primary care level, it is
also very important to address the relative lack of qualified mental heath
professionals trained to work with children and families who would do the
actual treatment of the children once they are identified.
- Although developing a consensus list of evidence-based treatments is an
admirable goal, we must recognize that we know very little about effective
interventions for the full range of mental health problems in children. There
is a need to understand more about childhood disorders within the context of
family, peers, school, home, and community. This will help us see how
children with different sets of symptoms and different needs respond to
different types of interventions. To increase the use of evidence-based
strategies, new modes of collaboration are needed between researchers,
parents, providers, and practitioners. To increase the relevance of
treatment studies, more research is needed to understand children in diverse
"real world" settings, and to measure improvements in symptoms, as well as in
functional outcomes such as how children are doing at school, family and peer
- Finally, it is also a worthy goal that we utilize evidence-based standards
for practice. However, although establishing incentives for this are
important, they are not enough. We must recognize that mental health
practitioners are too busy to take substantial time away from their practices
to learn new treatment techniques. Furthermore, for some of the more complex
treatments the traditional weekend CE format is not sufficient. Hence new
methods of post-degree training of mental health practitioners are needed.
These methods might involve such distance education formats as on-line
learning and compressed video. Research into the effectiveness of varying
methods post-degree training is also indicated.
Ronald F. Levant, Ed.D., A.B.P.P., is Recording Secretary of the American
Psychological Association. He was the Chair of the APA Committee for the
Advancement of Professional Practice (CAPP) from 1993-95, a member of the
Board of Directors of Division 42 (1991-94), and a member of the APA Board of
Directors (1995-97). He is Dean, Center for Psychological Studies, Nova
Southeastern University, Fort Lauderdale, FL.Reprinted with permission of the author.
CURRENT TOPICS IN PSYCHOLOGY White House Meeting (3-2000)