Healthy Kids, Less Crime? Part II of II

In Part I of this post, I discussed the policy implications of recent research from Duke University showing a clear link between mental disorders in children and their criminal activity as adults. I particularly focused on the impact quality child care and poverty reduction can have as a means of improving mental health—and thus, potentially prevent crime. Part II, which focuses on education, health care, and the juvenile justice system, follows below.

But a high-quality continuum of mental health services can’t only engage with preschoolers. The reality of life is that people develop at different rates, and the kid who's quiet at age 3 can become a hell-raiser at age 9. As such, schools have become a particularly important site of diagnosing and treating mental health problems among children.

For all the problems public schools face today, there has been some progress on the mental health front. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 70 to 80 percent of children who receive mental health services get the aid from school-based mental health service providers (e.g. guidance counselors, school psychologists, etc). Many schools have coordinated programs of education, observation, and counseling that partner up with community health experts.

But there's still a ways to go. The American School Board reports that there are around 1,700 school-based health centers in the United States, a tiny fraction of the nation’s nearly 90,000 public schools. There are many reasons for the relatively small number of centers including the basic difficulties that come with implementing what experts call an "ecological" model of mental health. This is a fancy way of saying that schools that are serious about mental health can't just have mental health resources; they must integrate those resources—educational materials, counselors, information, activities, etc—into the every day school environment (e.g. classes, discipline, etc).

This is, as you might imagine, a costly undertaking, and research from SAMHSA has found that low-income and minority schools are far less likely to have mental health programs in place. Those that do often have very limited programs.

Making things worse is the fact that the lion's share of funding for school mental health services is highly fragmented. The dollars come from disparate sources like state pools, the Individual with Disabilities Education Act, the Safe and Drug-Free Schools and Communities Program, the Elementary and Secondary Education Act of 1965, and even Medicaid and SCHIP. Dealing with these different funding streams--and the requirements attached to each--inflates the administrative overhead needed to manage funding.

A SAMHSA survey found that almost 50 percent of schools cite the complexity of multiple funding sources and restrictions on the types of services as barriers to providing kids with care. The work of schools would be a whole lot easier if funding was streamlined and consistent. A fractured system places extra burdens on already struggling institutions.

So where does health care fit into all this? Somewhat predictably, research shows that children with better access to health care are more likely to receive the mental health services that they need. The Urban Institute has shown that “44.9 percent of Medicaid/SCHIP children with reported emotional or behavioral problems used a mental health service, about the same as children with other (mostly private) insurance (41.0 percent), but over three times as high as uninsured children (13.7 percent)." Health coverage gives more kids access to more services.

But "more health care" is no silver bullet. Consider the fact that Columbia University research has shown that 79 percent of children with private insurance have unmet mental health needs. The problem goes beyond health coverage. 

That’s because, while coverage provides access to care, it means little if the care is lacking—and pediatrics has a long way to go before embracing an effective mental health model. In a 2004 article in Pediatrics, Edward Schor, M.D. notes that preventive mental, emotional, and behavioral care “receives little emphasis in pediatric training, reluctant consideration by insurers, and rare attention from researchers.” Writing for the Commonwealth Fund, Schor summarizes some of his most striking findings:

• 94 percent of American parents report unmet parenting guidance, education, or screening needs by pediatric clinicians.
• Minority or economically disadvantaged parents are two to four times more likely to express dissatisfaction with the growth and development care their children receive than white, non-poor, insured families.
• In a national survey, 36 percent of parents of young children reported not discussing significant specific, recommended child health issues with their pediatricians.
• In one large study, 40 percent of parents of children covered by Medicaid were not asked by pediatricians whether they had concerns about their children's learning, development, or behavior.
• The official schedule for pediatriciac visits is based mainly on immunization requirements, not the pediatricians' traditional holistic consideration of a child's health and concern for children's development.
• Children attend fewer than one-half of the recommended well-child visits, even when there are no financial barriers.

“Well-being” should be part our understanding of child health,” says Schor, and he recommends creating  an official manual of pediatrics best practices and a more focused sequence of pediatrician visits centered on different themes (e.g. “Understanding Your Child”). Perhaps most importantly, Schor notes that “early childcare and special education, welfare, foster care, and education” are “natural partners for pediatrics and pediatricians and should be enlisted not only in caring for individual children but also in formulating national policies that define the desired outcomes of, and thus support the need for, high-quality well-child care." In other words, we need to address childrens’ mental health through a coordinated response that winds through the entire social safety net.

Schor is exactly right about this collaborative approach—not only because mental health extends beyond medicine, but because pediatricians need all the help they can get. According to numbers Maggie has previously pulled from Merritt, Hawkins & Associates, a national consulting firm that specializes in recruiting physicians, pediatricians are some of the lowest paid physicians across various specialties. Given the debt associated with medical school and the mega-bucks that other doctors can pull in—the average orthopedic surgeon in 2007 made more than 2.5 times as much as the average pediatrician—there is an imperative for pediatricians to see as many patients as possible. This is not conducive to a holistic, integrated approach to child well-being. For pediatricians to effectively participate in a more coordinated wellness system, the salary crunch needs to be resolved. 

But even if pediatricians were to suddenly become millionaires, nothing would change unless the other factors—child care, poverty, and education—also changed for the better. Similarly, the last piece of the puzzle in thinking about crime prevention—the criminal justice system itself—would have to refocus on youth rehabilitation for this collaborative continuum to really work. Right now, it's only making things worse.

In 2002, the National Institute for Mental Health funded the largest study to ever look at mental disorders in juvenile offenders and found that 65 percent of boys and 75 percent of girls in juvenile detention have at least one mental disorder. With the prevalence of mental disorders among kids in the juvenile justice system more than three times higher than it is for other children, you’d think that juvenile justice would double as a gateway to rehabilitative mental health services. Not so. 

The penchant America shows for unproductive incarceration in adults also holds true for children. For example, the National Center on Substance Abuse at Columbia University found that of the 2.4 million juvenile arrests in 2000, 1.9 million involved substance abuse and addiction but that only 68,600 of those arrested received any substance abuse treatment. According to the Campaign for Youth Justice, only 11 percent of jails that house juveniles provide for special education services—despite the fact that some 30 percent of inmates younger than 24 have learning disabilities.

Perhaps the worst offense of the system is its conflation of young offenders with adults. Throughout the 1990s, forty-five states passed reforms that made it easier for children to be tried in the adult criminal justice system. Since then, most children have been detained pre-trial in adult jails rather than juvenile detention centers, where they are at a much greater risk of physical and sexual assault.

Obviously, jail is no place for children—especially disturbed ones. A November report from the CDC found that involving children in the adult criminal justice system makes them more violent. As the director of the Georgetown Center for Juvenile Justice Reform told the Washington Post, "you couldn't ask for any worse results. We're getting faster recidivism for more serious crimes." In Florida, for example, youths sent to the adult system had 34 percent more felony re-arrests than those retained as juveniles, despite having equivalent crime records. If pediatrics ignores mental health, the criminal justice system actually worsens it—and with the infrastructure for child welfare already so precarious, that’s the last thing we need.

Unfortunately, in recent years juvenile justice has seen the same amount of national political attention as general crime has—that is to say, very little. Today politicians keep mum on crime because they don’t quite know what to say. They can't stir fear, because crime is low. They can't take credit for the crime drop, because no one knows why it happened. What’s a vote-hungry politico to do?

He might start by embracing the Duke research and its policy implications. Childhood mental disorders are complex dilemmas, tied to a variety of social circumstances—and if they predict crime, then our thinking about crime should be commensurately complex.

That means moving beyond our obsession with enforcement and punishment. Instead, we should think abut how child welfare translates into adult behavior—and how our social policies can complement each other to promote healthy development. True, there’s no guarantee of total success.  No doubt, there will always be criminals among us.  But what better time to roll out a full rethinking of crime prevention than when the crime rate is low—and thus the wiggle room for trial-and-error is high?

At the very least, we'll see a stronger social safety net that will benefit everyone. And at best, a generation will come of age in a society that’s finally taken measures to ensure them a healthy future. 

Comments

[morshaldock]

It seems that John McCain may have stolen some of the fire that Democrats traditionally wield on health issues by making cost control his top priority.
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morshaldock

Florida Drug Rehab