Why are we spending billions of dollars on costly, ineffective and even unsafe mental health interventions for children? I am referring to ineffective psychotherapies, disruptive out-of-home placements that may re-traumatize children, and inappropriate medication combinations? How does continuing these practices increase risk exposure to states and agencies that fund and provide them? Do we, collectively, have our heads in the sand? And is your state or agency at risk?
Over the last two decades it has become increasingly clear that our mental health systems for children are failing them. Children who receive many traditional (and often expensive) mental health services are often no better off (and sometimes worse) than children who do not receive them. This is a costly investment with no apparent return. And it puts agencies and state programs at risk through their support of these ineffective programs! A recent report (Zima, Bussing, Tang et al., J. Am. Acad. Child Adolesc. Psychiatry, 2010; 49:1225–1237) offers us an especially sobering case in point, using 4 data sources within a managed Medicaid program to determine which services are provided (or often not) for children with ADHD within a large county health system.
ADHD is a good case in point, because 3 decades of research have clearly established a) which treatments work and which do not, b) the cost-effectiveness of carefully delivered treatments vs. routine care or no care (Jensen, Garcia, Glied, et al., 2005); c) the resulting healthcare and societal costs, as well as lifetime burden of ADHD on adult functioning, the workplace, families, healthcare settings, and the justice system; and d) the general failure of our systems to improve ADHD care, despite the abundant available data in a, b, and c above to guide better practices.
The report by Zima et al. is provocative on many fronts. For starters, it focuses on public funding (Medicaid), indicating that we taxpayers are footing the bill. Secondly, it shows that almost half (44%) of children receiving the diagnosis of ADHD do not receive follow up care in the 6 months after the initial period of diagnosis. Third, it shows that children with ADHD who receive services in primary care vs. specialty mental health care settings do not differ in terms of case severity/complexity. This signals a lack of appropriate triage and decision support mechanisms to ensure that children receive different levels of care based on their individual differences. It also points to a gross mismanagement of scarce specialty mental health resources. And lastly, it shows that if a child comes for ADHD treatment into primary care settings, he/she only gets medication, and only rarely psychotherapy; if she/he enters the mental health system with the same diagnosis, she/he only gets non-specific therapy, not any of the proven psychotherapy methods, and rarely medication.
Contrast these grim real-world findings with what we know works: yes, medication treatments of ADHD are quite effective, but not in the sporadic, minimal follow-up approach typical of most real world practices. And yes, certain forms of evidence-based psychotherapies are also effective (specific forms of behavioral therapy and parent management training), but unfortunately most therapists across the US are not trained in these methods. In fact, most studies, including the one by Zima and colleagues have shown that poorly specified “treatment as usual” therapies are not more effective than waiting lists.
So what is my own risk as a clinician, if I were to continue to deliver what I “feel” is good treatment, even though abundant scientific evidence and a federal Consensus Conference panel (NIH, 1998) and many treatment guidelines (e.g., AAP, 2000, 2001) say my approach is ineffective? If the family were to find out that I had been giving their child outdated, ineffective treatments, would I at least be liable to pay back any costs they or their insurance company paid for this care? How about if the family and child were to have very bad outcomes, such as increasing delinquency, school failure, depression or suicide? Would there be punitive damages? If you are unsure, how about if one of us had a surgical procedure but the doctor did not use sterile technique, and that person got a post-op infection and died? Yes, mental health is not as certain as surgery, but there is little scientific uncertainty in how doctors should diagnosis and treat ADHD.
But there is some hope that things are changing. In a relatively quick search I conducted on the web, I found multiple sources that have documented the many class action lawsuits against states and agencies over the last 15-20 years for failing to provide appropriate mental health services to children and youth in need (e.g., see Child Welfare Consent Decrees: Analysis of 35 Court Actions from 1995-2005, Child Welfare League of America). Within the child welfare system alone, between the years 1995-2005, in 32 of 50 states where class action lawsuits were filed, consent decrees or settlements were obtained in 30 of these. Not confined to child welfare, similar trends are now happening in special education, justice, and child mental health systems, including the requirement in some consent decrees and settlements that the defendant (state or agency) be required to delivered evidence-based (proven) treatments, not just any type of care. Of note, in 51-76% of consent decrees or settlements, courts stipulated additional requirements to provide better or more appropriate mental health assessments, increased staff training and supervision; and creation of information systems and/or quality assurance reviews.
So here’s the challenge for our states and agencies: Our workforce is largely unprepared. Most providers in mental health services completed their training over 20 years ago, well before the current explosion of information about evidence-based psychotherapies, pharmacotherapies, and preventive interventions. Interestingly, my colleagues and I conducted a survey 2 years ago of experts within the child welfare system about credible means of training the workforce in evidence-based techniques. What did that survey show? In the accompanying table, you see the results of the survey of over 40 experts who rated various methods for helping current staff learn and become skilled in evidence-based treatment methods: 6 different methods for receiving training in evidence-based methods were rated on a 1 to 9 scale: reading printed materials and books; brief-video-based training; supervisor consultation; didactic workshops with no follow-up by the training team; intermittent consultation with experts; and hands-on workshops (role plays, videotapes, tailoring to each participant, etc.) with sustained follow-up and coaching support. The 9-point scale had the following definitions: 1 = not at recommended, i.e., a poor or inadequate training approach, 5 = neither fully acceptable nor wholly unacceptable; 9 = a best practice or state-of-art training method. What were the results? Reading printed materials (3.0); Brief-video-based training (4.1); Supervisor consultation (4.6); Didactic workshop only (4.9); Expert consultation only (5.9) Hands-on training workshop and sustained follow-up (8.5).
As these results illustrate, only hands-on training with sustained follow-up was judged by experts as an appropriate method for teaching evidence-based practices, with this approach receiving mostly “9s”.
But how is this type of training for current clinicians to be received, whether it be sustained training and coaching in delivering evidence-based psychotherapies, or sustained, hands-on training in using medications safely and appropriately?
When I travel across the country, one of the favorite questions I put to professional audiences is as follows: “By show of hands, how many of us have been trained in manualized, evidence-based therapies such as CBT or behavioral therapy by a supervising therapist, with training on individual cases lasting at least 1 year?” Among psychologists, the result is generally 1 hand in 5, among child psychiatrists, 1 in 10, and among clinical social workers, 1 in 20. This finding is even more staggering when we stop and realize that in 20 years, there will be still newer treatments that have been developed in the interim that only graduates in the last few years will know. Unless we find a way to create “dealerships” whose mission is to get the latest treatments out of the factories and to disseminate and teach others in their use, we will always be about 20 years behind the “evidence-based treatments” implementation curve.
What can you and I do? First, we need to realize that learning an evidence-based intervention is a gradually acquired, slowly learned, complex skill, much like learning how to swim. It can’t be learned by a single lecture, web course, or a hit-and-run Power Point presentation, any more than non-swimmers can watch a video on swimming techniques and immediately jump in the deep end of the pool. But it can be learned. Resources exist to support learning these skills. At REACH we have developed partnerships with many of the nation’s leading psychotherapy and pharmacotherapy treatment developers to craft clinician-friendly treatment training methods, so that our children and families can obtain state-of-art, evidence-based assessment and treatments from expert clinicians right in their own communities. No child should have to wait 20 years for a more effective treatment to become available in their home town, when it already exists in researchers’ laboratories. And no one should have to travel to a high-powered research university to get good care.
I’d welcome your thoughts!
Peter Jensen
5 Comments
The data is accumulating, especially in the EU, about the benefits of treating ADHD in the criminal justice system, b0th adult and juvenile. If we change the focus to inner city poverty areas, while recognizing ADHD is not a “class” disease but affects those in all levels of society, consider the effect of ADHD on the opportunity of a child to grow out of poverty. The social (peer) influences as the child gets older may be more difficult to manage with ADHD. With ADHD as a generally heritable condition, the presence of ADHD in the parents, especially the mother, may compromise effective treatment in the child. I am not saying ADHD causes poverty, or generates a social environment that includes gangs, drugs, and crime. I am also not saying that ADHD treatment is a panacea for solving poverty. What I am suggesting is that failure to recognize and aggressively treat ADHD in both the child and parent in this environment leaves a nearly impregnable barrier to the opportunity to rise out of poverty. It is truly a social justice issue.
A comprehensive evaluation and treatment team are needed to adequately take care of children with mental illness. It also requries structuring the environment at home and at school. Most children with mental illness seen in our practice have severe and complex disorders. They are usually escorted by adults who have serious difficulties of their own: substance abuse, mental illness, domestic abuse or violence backgrounds, limited education, medical illness, and/or poverty. In studies of children who do “no better” after having been treated for mental illness, are these factors measured or tracked? One can be quite skilled in pharmacotherapy and psychotherapy and still not make a difference if the child doesn’t have basic needs met. Poor parenting trumps good psychotherapy 90% of the time.
I totally agree with Sue Jenkins that if I had to choose between good psychotherapy and good parenting, I’d go with good parenting almost every time, certainly for younger children up to the teen years. But it is important to remember that some of our best therapies focus very specifically on assisting parents with developing optimal parenting skills, so in these situations, good therapy and good parenting are one and the same.
The other excellent point made by Dr. Jenkins is that children’s basic needs for security, safety, friendship, developing their talents, good school performance, etc., are essential to optimal mental health outcomes. I and my colleagues have actually been developing therapies that address these critical issues, so we don’t want to create an artificial boundary between good therapy and achieving optimal environments for children. They should be one and the same.
Peter S. Jensen, M.D.
I have concerns for students receiving less efficacious and even detrimental therapies as well as specific concerns for my own discipline as a related service schools. Students with mental health needs often receive no support at all and when supports are provided in schools, those may be strictly behavioral even when that approach is contraindicated. While strength based approaches such as wraparound are indicated in our state plan, very few school-based personnel are familiar with them, much less skilled in their use. And unless their role is specifically tasked with implementation, related services and other education personnel may not be allowed to support wraparound.
As an occupational therapist working in schools, I am frustrated at the frequent push to expend resources on practices that have very limited evidence bases from peers outside of the system. I have knowledge and skills but I am not given time based on my professional judgment; my time is drawn away from supporting student success for under-served students with mental health needs. My field needs to do a better job of research around the use of occupation-based interventions to support student capabilities and evidence based practice in the school environment. But to have the capacity to do so, we have to be able to set limits on expending our resources on non-evidence based practices.
Claudette, you make an excellent point that the costs for unproven services and interventions can crowd out more effective, critical intervention resources. To my mind, this is where individuals’ self-interest and children’s interests may collide: an educator, a healthcare provider, a given profession, or a service agency may advocate strongly that what they do is essential, but unless 1) there are outcome data demonstrating that the particular intervention is effective, and 2) unless procedures are in place to ensure that the effective intervention is done with fidelity and quality procedures in place, it is all matter of making claims and assertions, i.e., faith without works. When claims and passionate beliefs are in fact empty promises, then children and families suffer while child health providers’ and educators’ jobs remain secure.
Peter S. Jensen, M.D.