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

Simply stated, across the country those looking for “quality” in children’s mental health services may be putting the quality cart up front, and flogging a weary horse to push quality up a steep hill.  Who are the horses? Not just clinicians, but the clinical service delivery systems that have to work together to pull the cart up the quality hill.  So let’s stop for just a minute and think about what we our vision would be for a quality-driven clinical service system for families with children with significant mental health challenges:

A Vision for Quality Mental Health Services for Children and Families

In this system, imagine that the child and family walk into an office, where a cheerful receptionist greets the everyone by name.  The client is handed a tablet computer with a brief survey comprised of checkboxes and dropdown menus asking questions related to the patient’s current well-being and follow-up questions since the last visit.  Data from this survey are transmitted directly to the clinician, enabling him/her to know exactly why the patient is in the office today and allowing ensuing discussion of treatment to be streamlined and targeted.  Doctors and patients alike are given helpful prompts by the system, not just to avoid medical errors, but also to remind all parties when the client needs a blood test or examination.  Clients also receive personalized summary reports for their own records, and referring doctors and other health care team members are kept fully in the loop with frequent and regular status reports, thus ensuring better coordination among different health care providers.  Billing is done automatically, but always based on family’s income and ability to pay.  Complicated mental health problems are addressed by the necessary combination of team expertise and support –  psychotherapeutic, medical, educational, social, and community, with carefully constructed, solid bridges built for each family to help them help their child succeed, regardless of income or ethnic background.

This system would incorporate everything that our current systems lack:

• This health care setting not only serves clients, but also serves the community.  Every member of the staff feels the desire to give back to the community, and to be accountable to the community.
• This health care setting includes all of the necessary team members to address the child’s and family’s needs, including an accurate and comprehensive diagnosis, assessment of child & family strengths, research-guided therapy and rehabilitation, and provision of ancillary support.
• The health care operation serves a diverse socioeconomic community, including patients capable of full payment through those reliant on Medicaid
• The office runs on a comprehensive software system, with 21^st century capacities: capable of electronic billing, creating a newsletter and reminders that can be e-mailed directly to clients, comprehensive reports and records immediately available to the family and referring professionals, and other documents needed to inform and guide current treatment
• Within the software system, crucial information is shared virtually immediately among all team members (including the family), as well as schools and other providers, such that all stakeholders invested in the child’s (and societal) well-being receive the necessary information and feedback to apply optimal methods, employ corrective steps when needed, and achieve optimal outcomes.

Such a system must be structured to maximize three essential elements: 1) the family’s personal and interpersonal experience of the services delivery;  2) the scientific rigor and effectiveness of all services offered; and 3) aligning all procedures with the right “the patient comes first” values within a sustainable business model: let’s see what these entail:

1) Maximizing the personal and interpersonal experience for families and clinicians

-     a) procedures for engaging the child and family; b) procedures for developing agreed-upon and shared understanding of problem; c) use of collaborative problem-solving model, d) ongoing problem identification, open discussion, and working out problems together; ie., a true partnership vs. “doctor knows best”; e) user-friendly and rigorous assessments that also serve to track ongoing optimizing of process and outcome, with a collaborative feedback system between clinician and family; two-way communication focused on problem solving and improvement; f) minimal paper work or computer entry; all data input/paperwork are incentivized and provide feedback to persons giving it; g) assessments are adaptable for current standard of practice, DSMIV, ethical standards, and billing systems; h) interpersonal processes measured from multiple informants, with feedback shared with all in collaborative process; i) helpful reminders to clinician, child, and family for completion of necessary assessments and feedback; j) ongoing ease of access to services, with caring, knowledgeable individuals “in-the-loop” about the family’s needs, available 24/7; k) a safe environment to discuss billing issues, financial worries, impact on child and family; l) all complex, sequenced activities are assisted by computer aids or other supports; m) decision-aids to families and clinicians about choices that are available to them; m) access to community and social supports outside of traditional medical model, with the clinical system providing active linkages to these additional services; n) child /family assessments, with individual child/family prognosis, treatment, and outcomes presented to the family based on references to research-based standards; o) the child & family’s experience & perceptions of quality and efficiency is sought, and used to further maximize and improve individual care and larger system; p) treatments are tailored to individual families, with emphasis on child & family input, choice, and control; q) all clinical processes are transparent to families, with active educational efforts directed at all steps of assessment and intervention, and their rationale.  An active mentoring/coaching approach by the treatment team is critical, rather than a “trust me, the doctor knows best” approach; r) impact of the amount of time spent with families and perceived time pressures is monitored; and s) there is ongoing going communication about families’ needs; these are shared among team members via systematic feedback with the entire problem-solving team (including families, who are the most key members of the team;

2) Maximizing scientific effectiveness

-     a) Identification and ongoing implementation of evidence-based, “best practices”; b) creation of culture of the need for ongoing improvement among all staff; c) commitment to and completion of ongoing training in EBPs; d) ongoing assessment of clinical quality processes by patient, by clinician, by treatment type, with feedback and correction to clinicians and clinical staff; e) collaborative problem solving among clinicians and scientists; consumers, with commitment by all to scientific method; f) comparing outcomes across clinicians and clinics, referencing processes and national standards, and giving improvement feedback and assistance where needed; g) ensuring rigorous data collection so that every family, every clinician, every procedure, and every practice setting contributes to improved knowledge and scientific understanding; h) ongoing process to identify most important knowledge gaps in clinical procedures

3) Maximizing optimal alignment between key values, systems/structures, human processes, science-based procedures, outputs, and sustainability and dissemination

-     a) Mission, appropriate values, and a strategic planning process drive all decisions; b) this system must use a “social business” model – delivering a high quality, much needed product at affordable cost where all costs are covered in a sustainable business model, and secondly, the products and services provide  value-added to society, both short- and long-term; c) business model involves simultaneous promotion of public health values, with transparency of all budgeted  funds and income; d) business model must be tailored  to local markets; e) those who devote funds to start up and develop such programs must receive return on principal, and perhaps a small return on the investment.

Unanswered Questions about Quality Mental Health Services

Members of the REACH Institute, along with a group of like-minded individuals, are now pursuing the active study of what this type of quality costs.

Several questions to be asked and answered.  Please weigh in with your own views, and respond to our initial answers:

Q1) Can it be done?

Answer: Yes, these technologies are now available to us.

Q2) Would you want this for yourself and your family?

Answer: Most certainly.

Q3) Can we afford it?

Answer: That’s the big question.  We think so, if we take a population-based approach, and share costs across all income levels, using a sliding scale based on income and ability-to-pay.

Q4) What other elements of “quality” are needed, and are there any elements I have mentioned that you would feel are superfluous or not needed?

Your thoughts?

pj

Peter S. Jensen, M.D.
President & CEO, The REACH Institute &
Professor of Psychiatry & Co-Chair
Division of Child Psychiatry & Psychology,
Mayo Clinic – Rochester

* 41 million uninsured Americans exhibit consistently worse clinical outcomes than the insured, and are at increased risk for dying prematurely (Institute of Medicine, 2002; Institute of Medicine, 2003a)

* The lag between the discovery of more effective forms of treatment and their incorporation into routine patient care averages 17 years (Balas, 2001; Institute of Medicine, 2003b)

* 18,000 Americans die each year from heart attacks because they did not receive preventive medications, although they were eligible for them (Chassin, 1997; Institute of Medicine, 2003a)

* Medical errors kill more people per year than breast cancer, AIDS, or motor vehicle crashes (Institute of Medicine, 2000; Centers for Disease Control and Prevention; National Center for Health Statistics:  Preliminary Data for 1998, 1999)

* More than 50% of patients with diabetes, hypertension, tobacco addiction, hyperlipidemia, congestive heart failure, asthma, depression and chronic atrial fibrillation are currently managed inadequately (Institute of Medicine, 2003c; Clark et al., 2000; Joint National Committee on Prevention, 1997; Legorreta et al., 2000; McBride et al., 1998; Ni et al., 1998; Perez-Stable and Fuentes-Afflick, 1998; Samsa et al., 2000; Young et al., 2001)  log

Problem Statement, Background, & Our Assumptions:

Failure to apply recent research findings about effective treatments is a critical problem that spans all areas of medicine, including child and adolescent mental health services.  According to the Institute of Medicine, the lag between discovery of a new or more effective form of treatment and its widespread application averages 17 years across all areas of medicine. In the mental health arena specifically, experts estimate that more than 50% of adults with depression do not receive appropriate care.  In the child mental health area, McLennan and colleagues noted that research-practice gaps can be considered to fall into 4 different categories – in essence one sin of omission and 3 sins of commission: 1) failing to implement procedures that have been shown to be effective; 2) implementing procedures that have been shown to be harmful; 3) implementing procedures that have no effect; and 4) implementing approaches that not been studied (McLennan et al., 2006).

In this blog we take a “big picture view” of what we believe are some of the key policy, structural, and economic problems in closing the research practice gap, and offer several potential pathways for future progress, in terms of necessary new policies, structures, incentives, and conceptual paradigms that may enable the child mental health field to shorten the research-practice gap.

Background:

Despite the general awareness of the field of the quality chasm in translating research findings into practice, in the child mental health services area there has been little explicit study of the extent and nature of this research-practice gap, in terms of formally documented reasons for the gap, and the extent to which it applies across specific childhood disorders, treatment types, provider disciplines, clinical populations, or environmental contexts.  Even within the best-studied disorder area of ADHD, evidence indicates that clinicians do not apply recent research findings developed by multiple professional and advocacy organizations.  While accreditation measures have been developed for ADHD, the National Committee on Quality Assurance studies indicate widespread failure to implement basic standards.  No measures have been developed or applied for any other area of child mental health diagnosis and treatment services, not even common problems such as adolescent depression across most settings or plans.

Why is Research Often Not Applied to Practice? In other areas of medicine, the research to practice translation gap has been more thoroughly examined (e.g., cancer, diabetes).  Generally speaking, four major reasons for translation difficulties have been identified: 1) Intervention characteristics (e.g., cost, time demands, level of staff expertise required, difficulties learning the intervention, failure to package “manualize” the approach, failure to develop the intervention considering users’ needs, failure to consider how to make the intervention self-sustaining, failing to make the intervention modular or customizable, intervention specificity to a particular setting, etc.); 2) problems with studies’ research designs (e.g., study populations not relevant or representative, failure to identify critical outcome variables for the intervention; failure to study key variables needed by policy makers and communities prior to adoption, such as cost, reach, implementation, maintenance, and/or sustainability factors); 3) problems with intervention adoption settings (e.g., competing demands, program imposed from outside, financial/organizational instability, specific needs of clients and setting, limited resources, time, or organizational support; misaligned incentives or regulations; competing prevailing practices; and challenges to intervention implementation quality), and 4) Interactions among the three above barrier types (participation barriers reduce program reach or participation, inflexible interventions, interventions not appropriate for the target population; organization and intervention philosophies not aligned, etc.).

While we agree with the general outline of these “reasons” for translation difficulties, these reasons tend to be rather molecular in focus, and in fact might mislead healthcare system organizers, policy-makers, and planners to simply continue to tweak existing interventions in order to try to close the research-practice gaps, piece by piece, bit by bit.  While we believe that such an approach has some merit, we also believe that such an approach will yield modest (if any!) results in closing the gap.  The current list of reasons does not fully consider the backdrop of larger clinical and community factors and forces, against which new evidence-based interventions must compete, if they are to be successfully implemented.  Taking these factors into account must be considered as paramount for a successful strategy in closing the research practice gaps.

We also note that the research-practice gap also partly overlaps with other known gaps in access and effectiveness, such as health care disparities as a function of ethnicity, region, and income.  These gaps must also be considered as a part of the overall difficulties in improving care and closing the research-practice gaps.

Four Key Assumptions:

The strategies we outline below are based on 4 key assumptions, or beliefs.  While we believe our assumptions are reasonable and likely correct, each assumption itself might be the subject of study and debate;  this is a task beyond our immediate scope of responsibility.

1. “Teaching Old Dogs New Tricks”: New Research Often Not Implemented By Clinicians, Even in the Absence of Barriers. Many current “evidence-based practices” in mental health assessment, prevention, and psychosocial and pharmacologic treatment are available, but are not well-implemented.  Even in instances where health care barriers are minimal (e.g., with 100% insurance and health care access), clinicians do not deliver (and families fail to receive) treatments consistent with the most recent evidence. To illustrate,

Within the well-studied disorder area of ADHD, decades of research findings are available, and treatment standards based on recent research findings have been developed by multiple professional and advocacy organizations and the NCQA.  Yet in a recent NCQA validation study across 6 health plans for the “ADHD diagnosis initiation quality indicator,” applying the simple standard of requiring an ADHD diagnosis to be captured in the follow-up claim, with >2 additional follow-up visits in the next 11 months, plans’ average visit compliance rates were 19 percent and 23 percent for commercial and Medicaid plans, respectively. Across all commercial plans providing information 2005-2007, 90% of insurers averaged less than 45% on the quality measure of achieving minimal follow-up visits after ADHD diagnosis, with the mean percentile across all health plans of less than 33%.  No evidence of change was noted across the years 2005-2007.

This example of ADHD reflects only a limited view of what is widely believed by most scientists as the much larger research-practice translation problems across all of medicine.  We note, however, that the IOM’s assumption of a 17-year research-practice gap across all of medicine may or may not be correct, and this concept of a 17-year research-practice gap has never been operationalized and rigorously applied to child mental health.  We believe that we lack any specific details of the research-practice gap, in terms of which areas are most affected, i.e., populations, disciplines, disorders, settings, etc.  For child mental health researchers, policy makers, and the general public to fully tackle this problem, the gap needs to be defined and operationalized with publicly vetted and accepted scientific measurement approaches, so that the gap indicator itself can be used as a feedback tool for the field to monitor its difficulties and measure its progress (or lack thereof).

2.  Developing New Types & Models of Health Care Practice Organizations. We believe that the current alignment of federal, state, and local economic incentives that a) pay for health and social problems but not their prevention; b) pay for clinical and educational training models that consider children’s mental health and educational outcomes as discrete rather than inter-twined, c) stove-pipe funds and responsibilities for care and outcomes within but not across systems; d) focus solely on treatment of individuals vs. the management of populations; and e) assume patients to be passive recipients of an expert-delivered, short-term, finite/discrete product or service –  all 5 of these factors distort/prevent the application of more efficient, evidence-based procedures.  Health care organizations as bureaucracies are usually organized around these distorted economic incentives, so rather than taking advantage of new information systems and findings from social neuroscience about how to best design optimal human service organizations, health care systems tend to perpetuate the older, familiar models. We believe that without fundamental changes that tie incentives to outcomes-based feedback and performance for individuals, populations, and health care organizations, change and application of EBPs will spotty at best.

To test the assumption that economic incentives will facilitate the adoption of EBPs seems reasonable, but it is important to note that previous studies indicate an uncertain relationship between economic incentives and subsequent provider/clinician behavior.  Perhaps even more importantly for child EBPs, the questions of whether EBPs make economic sense might be evaluated using a range of tools, including benefit-cost analyses (BCA) and cost-effectiveness analyses (CER). BCA provides a full accounting of the resource implications of an intervention, policy, or program. One measures both the costs and benefits of the intervention and then calculates net benefits—that is, the benefits of the intervention less its costs. If the net benefits are positive, then the intervention or treatment is desirable. Unlike BCA, cost-effectiveness analysis (CEA) does not require one to measure outcomes in dollar terms. Rather, the outcome measures remain in their natural metric (e.g., a 1-point difference on a symptom checklist or a percentage point reduction in the number of teenagers giving birth). The analyst then compares interventions or programs in terms of their added (or incremental) costs per added unit of the outcome measure (Zerbe & Dively, 1994). One could calculate such ratios for a variety of outcome measures, comparing a standard treatment vs. an EBP.

Other areas might also be examined vis-a-via EBPs, such as mining various state, insurance, or federal data sets to examine the vast differences in children’s mental health services from county to county and state-to-state, or within and across service systems, to determine factors such as cost-shifting when funds are constrained in one setting, yet result in additional costs in other settings.  Optimal vs. non-optimal treatments for disorders like ADHD might be analyzed in various data sets to show how costs accrue over time to various service settings among families with unaddressed risk factors.  Likewise, studies need to be mounted that examine how changes in the organization of how care is paid for (e.g., payment to a provider for treatment of discrete illness episodes vs. payment to a health care organization in terms of preventing illness in a population of patients).

The current lack of coupling of children’s mental health services, outcomes, financial incentives, and economic understanding of this decoupling may be most evident in current situations where only persons with substantial economic resources may receive mental health care from a child psychiatric specialist, yet may or may not have any better outcomes!

3. Moving Research from Ivory Towers to Earthen Trenches: Translating EBPs to “the Real World.” Researchers who have developed EBPs often have little know-how how to take well – established programs out into “the real world”.  In fact, follow-up interviews of well-established investigators who have developed EBPs suggest that they often have disincentives for doing so, ranging from 1) lack of understanding how to adapt interventions to make them feasible and sustainable in the real world, 2) how to develop fiscal and business models to sustain EBPs deployment, to 3) ethical restrictions imposed by IRBs and universities if the possibility exists that researchers might profit from continuing to study and deploy the intervention.   In several instances, researchers have developed a business model (sometimes in partnerships with the university), have drawn upon SBIR funding, or have set up independent businesses.  These various strategies each have a number of advantages and disadvantages, and each entails a whole new set of activities which must be learned and mastered, for which many investigators appear unprepared or unwilling to pursue.

In the area of evidence-based school mental health interventions, for example, a review by Forman, Olin, Hoagwood et al. (in press) identified 25 EBPs for which 24 intervention developers were interviewed, fiscal stability was consistently cited as the most critical factors. For example, one intervention developer stated in describing a self-perceived lack of knowledge and skill to deal with implementation and sustainability issues, “I’m just a college professor who created a program.”  The unexpected and complex processes that are set in motion when a new program is introduced require preparation, a long-term commitment to overcoming numerous challenges, and many partners, much more like starting a successful business than conducting a narrowly defined research study. Additional efforts are needed to ensure that future EBPs can be implemented and sustained in practice settings..   We believe that stable business-savvy dissemination organizations and mechanisms that can assist researchers to “take research to market” are very much needed or at the least, integrated delivery systems with motivation to provide the best possible care must be linked with scientists who create such programs.

4. Rethinking  children’s mental health: a child psychotherapist for every family, or designing healthier communities? The child and adolescent mental health system with its emphasis almost exclusively on the individual clinician patient-encounter is seriously flawed.  Attempts to close the research-practice gap by focusing solely on this encounter will not succeed, due to range of factors that will prevent full implementation of EBPs, such as stigma about identification and treatment of mental health problems, problems with access to clinical services separated from community locations such as schools, etc.  We believe that effective strategies to close the research-practice gap (as well as other treatment disparities) will ultimately require a public health approach (e.g., see IOM Prevention Report, 2009), and other research-to-practice translational efforts will be incremental at best.

Studies that could be mined to help establish this point might include several of the recent child mental health clinical trials (MTA Study, TAD Study, and others), where data show that extra-treatment factors such as parent depression, family stress, social and community factors usually explain the largest bulk of variance in outcomes, particularly over longer-term periods. RCT data from studies such as the MTA also show that access, stigma, family concerns with specific treatments, etc., often undermine optimal deployment in clinical settings.

The Big Question

In this blog, we hope to capture your ideas about 1) the problems as we see them, and 2) what you see as possible solutions!

Peter S. Jensen, MD

President and CEO

The REACH Institute

co-authored with Kelly Kelleher, Marc Atkins, and Mike Foster

According to Cooper and colleagues’ findings, we have witnessed meaningful shifts in the culture of care in the last 25 years, often in specific regions and as a function of strong state leadership.  However, more in-depth analysis revealed that “changes, while promising, are often severely limited in scope and shallow in depth due to lack of concerted strategic plans.”

I agree.  It is ironic, even tragic, that NIH has spent over 2 billion dollars on child mental health-related research since 1990,  but getting this information and new methods out into our communities and to our families has hardly progressed whatsoever.  We have made remarkable strides in terms of developing better diagnostic tools and more effective treatments, but as a country we have not put into place the necessary mechanisms that take correct principles and proven programs to their ultimate destination — families.  And it truly is not “rocket science!”   Successful examples exist that indicate that the necessary steps are fairly straightforward.  When a discovery is made or a new finding is developed, four steps are needed to take it to market, at least in the child health and human services arena:

• Identifying and validating successful programs with the key stakeholder groups; a discovery won’t last long if it is repudiated by other scientists, or is felt to be unacceptable, unaffordable, infeasible, or unsustainable within larger communities.
• Adapting them for wider dissemination so that they fit the cultural needs of new communities, with those communities’ buy-in.  Rarely is an innovation fully ready for prime time right out of the university investigators’ laboratory.  Lots of input, adaptation, and modifications are often needed, where the researcher learns what the community really needs and wants…which may not be exactly what the researcher did.
• Disseminating the programs with the leverage of those communities, and assisting those communities to bring additional funding sources to the table as needed; and
• Empowering those communities to continue delivering the latest, scientifically updated versions of the programs through some kind of central, non-profit, publicly oriented support function.

These 4 steps often take years, and without careful assistance, they result in what the Institute of Medicine concludes is an 18-year science-to-service translational gap in putting science to work for families.  So the likelihood of any child or youth getting state-of-art, up-to-date care for mental health problems is small, unless the family travels long distance to one of the 4-5 universities doing the cutting edge research in that area.

However, in our experience at the REACH Institute, these four steps, done strategically and systematically, can be completed in as little as 3 years, when all the key stakeholders are quickly brought together, essentially forming a science to service dissemination pipeline.

Why the delays?  When I was at NIMH from 1990-2000, where I served as the Associate Director of Child & Adolescent Research, we often saw that the first two steps (identification and adaptation) would take years, often because most of our scientists naturally do what they were hired to do, and in fact do best: test and compete various programs in the market place of ideas, and then publish these findings in scientific journals.  As scientists we tend to debate for years in the pages of our journals about best methods, while families and community health providers remain confused about best practices.  In fact, while I was at NIMH, we only hosted one NIH- sponsored Consensus Conference during the entire decade while I was there…for ADHD in 1998.  So how are competing professional scientific discplines going to reach consensus on thorny issues like teen depression, or use of medications vs. psychotherapies?   And even if consensus can be reached with scientists and consumer stakeholders, who is there for the second step?  — to adapt the beta-versions (university lab prototypes) so that they are readied for distribution across the  science-to-service pipeline (if it existed).  Adapting the interventions to “the real world” and then helping others apply them, was not then, and is not now, a common function of universities.

While still at NIMH, Lisbet Shore’s book “Common Purpose” had a great impact on me.  She described the case stories of successful national dissemination programs, and detailed the factors associated with successful disseminaton.  One common factor was that successful programs usually had a hands-on, national training and technical assistance center that systematically helped new sites learn the program, adapt it to their communities, and then provided ongoing support and evaluation.

This is why the REACH Institute was formed in 2006.  Because the ultimate success of any program depends upon whether it actually “reaches” and helps children and families, key leaders from NAMI, CHADD, MHA, and FFCMH, serve on REACH’s Board to guide this process. In addition, because of the somewhat fractious nature of our field historically, as well as concerns about commercial interests, we established REACH with a great deal of interdisciplinary input, and obtained IRS approval as a 501c3 non-profit.  Its 501c3 status allows generous individuals invested in child mental health system reforms to make non-profit donations to bring the latest methods to their local communities’ health/mental health providers.  In addition, my own time on behalf of REACH is donated pro-bono, in order to avoid any misinterpretations about personal financial gain.

Now that REACH is up and going, I believe it has something to offer all of us interested in transforming children’ mental health and reaching all children across the country.  Speaking on behalf of REACH, we are are eager to partner with individuals and organizations at local, state and national levels, and across the range of provider disciplines and consumer voices that need to be involved to solve our problems. We are eager to make all of our tools and programs available to anyone committed to transforming children’s mental health across the country.

A brief one-pager describing some of REACH’s current programs is available at the link www.TheReachInstitute.org/documents/REACHintro.pdf.  Also, please drop me an email note if you have ideas on programs and partnerships that we might follow up on together.  Or to get a more extended view, please go the homepage and browse to your heart’s content, www.TheReachInstitute.org.

Happy Holidays!    peter jensen

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