Workforce Trends

Among all disciplines that provide mental health care to children, there is a striking trend toward the use of professionals who lack specialty training in child mental health. The bulk of psycho- and behavioral therapy is provided by social workers. Most prescriptions for psycho-tropic medication for children are written by pediatricians and family physicians, not psychiatrists. Experts across the professions generally agree that nonspecialists are not trained appropriately to be providing this type of care. But they do not agree on the extent to which more specialists should be trained, or generalists should retool, to offer children effective mental health care. Undergirding this question of an adequate workforce is the issue of money: the educational costs of becoming trained as a specialist are considerable, health plan payment rates favor lower-paid providers, and comparatively low payment rates are offered to the public sector mental health workforce.

The supply, practice patterns, and overlapping of the various child mental health provider disciplines is described more fully here.

Evidence-Based Care

Just as they have swept the physical health world, evidence-based treatments are now being developed for children’s mental health care to determine which medications, psycho- and behavioral therapies, and service strategies work best for a variety of conditions. The field is in its infancy. So far, evidence of effective strategies has been produced in university-based settings for a number of conditions such as depression, attention deficit hyperactivity disorder (ADHD), and anxiety and conduct disorders. But for the most part, these practices are not being used yet in real-world settings.

To qualify as a mental health evidence-based intervention, the treatment must work in more than one study using a randomized experimental design. However, there are no uniform standards developed for this field of science as of yet. The American Psychological Association has created rigorous criteria for defining effective psychotherapies. Another group that determines whether pharmacology treatments, as well as school-based interventions, are effective is the Interdisciplinary Committee on Evidence-Based Youth Mental Health Care, a joint effort of the AAP, the AACAP, and the American Psychological Association.¹⁷

These organizations’ studies of mental health have yielded some observations. When it comes to psychotherapies, parent training improves behaviors for children with conduct disorders and oppositional behavior.

Using non-phobic people as models of behavior and using reinforced practice can help children with phobias. For kids with depression, cognitive-behavioral therapy—where children learn coping skills and new ways of thinking instead of just discussing how they feel—has been shown to make a difference.

“What we see most commonly in usual practice is something called processing of experience or reflection. The therapist asks about the patient’s week. ‘Tell me about the argument. How did you feel about it?’ The session becomes an opportunity to have a sympathetic person think through the experience together [with the patient]. But usual practice is often not as structured or agenda-driven as evidence-based procedures,” says Dr, John Weisz, an expert in children’s evidence-based treatments and director of Harvard University’s Judge Baker Children’s Center.

“The difference between many forms of usual practice and evidence-based treatments is that [such treatments] have a skills-building agenda,” Weisz says. The therapist might ask “‘What thoughts did you have when you had this experience with your friend? Was that a realistic thought? What would be a more realistic way to think about that experience?’” Weisz says these questions would “have goals to build specific coping skills.”

Although there has been a tremendous growth in psychotropic medication use among children, there is little research on its safety and effectiveness. Most of what is known about such drugs that are approved by the Food and Drug Administration (FDA) comes from studies of adults. The FDA is only allowed to approve a medication for a defined population, but, once approved, physicians are allowed to prescribe the drug for anyone—a practice known as “off-label” use. The drug manufacturer, however, is only allowed to market the drug to the FDA-approved population.

Although there has been a tremendous growth in psychotropic medication use among children, there is little research on its safety and effectiveness.

The FDA has approved few psychotropic drugs for children’s use. Stimulants such as methylphenidate (for example, Ritalin) have been approved for treating ADHD. According to the surgeon general’s report on mental health, ADHD is the only condition for which there is a solid research base that medication works and is (at least in the short-term) safe.¹⁸ A major government study found that stimulants are more effective than psychotherapy alone in treating ADHD.¹⁹ However, the success hinged on close medication management, such as adjustment of doses once a month. Many children with ADHD have their medication checked much less frequently.

For treating childhood obsessive-compulsive disorder, the FDA approved in 1999 the use of two medications: fluvoxamine and sertraline (Zoloft).

To treat childhood depression, a growing number of medications in the class of selective serotonin reuptake inhibitors (SSRIs) are being prescribed for children, such as Prozac, Paxil, Celexa, and Zoloft. The FDA has approved only Prozac for pediatric use. Studies of antidepressant use among children have had mixed results, depending on the medication, and recently some studies have found increases in serious depression and suicidal thoughts and attempts by children using some SSRIs.²⁰

In response to public concerns, the FDA in March 2004 issued an advisory to clinicians, parents, and caregivers to “closely monitor all young patients on therapy with antidepressant drugs.”²¹ In June 2004, New York Attorney General Eliot Spitzer sued GlaxoSmithKline PLC, the firm that manufactures Paxil, for not publishing studies that showed negative impacts of Paxil on children.²²

A study published in August 2004 in the Journal of the American Medical Association (JAMA) found that a combination of Prozac and cognitive-behavioral therapy was the best method for treating adolescent depression. Seventy-one percent of the study’s participants who used this combination overcame their depression. The study, conducted by researcher John March and colleagues at Duke University and funded by the National Institute of Mental Health (NIMH), found that Prozac alone was effective in treating 61 percent of patients, whereas cognitive-behavioral therapy alone worked with 43 percent. Thirty-five percent of the study participants improved with a placebo.²³ The study also found a small but increased risk of suicidal behavior among children taking Prozac.

The link between children’s SSRI use and suicide was confirmed in September by an FDA advisory committee, which recommended that the FDA place a black box label—the strongest warning the agency could issue—on all antidepressant drugs to warn of the increased suicide risk among pediatric patients. The panel did not recommend a ban on antidepressants for children, noting that the drugs have shown benefit to some and that the risk of depressed children committing suicide if left untreated is higher than their risk for suicide on antidepressants. On October 15, 2004, the FDA announced the requirement of the black box warning on all antidepressant medications.²⁴

(Researchers have not been able to determine why antidepressants may increase children’s suicidal behaviors, but some theories are gaining attention. One posits that, during the first few days of use, the medication alleviates the lethargy felt by depressed children with suicidal thoughts, giving them the “energy” to act on such thoughts. Another suggests that, in some cases, children with bipolar disorder are misdiagnosed as having depression and prescribed antidepressants, which throw them into manic episodes that trigger suicide. Providers recommend closely monitoring children during the first ten days after beginning antidepressant use.)

The JAMA research has the potential for changing the way providers treat childhood depression. In an interview with National Public Radio, Dr. Harold Koplewicz, child psychiatrist and director of New York University’s Child Study Center, said he has been treating depressed teens by first using talk therapy and then moving to medication use. In light of this research, he told the reporter, “Today, if I had a teenager present with depression I would certainly tell [his or her] parents that medication should be started immediately and after the patient was on medication, we would start cognitive-behavioral therapy.”²⁵

Overall, the few evidence-based treatments that exist for children’s mental health problems are highly regimented; manuals have been written for implementing many of them. For the most part, they are not being used yet in private practice, public clinics, schools, and hospitals. This is not to say that all mental health providers are giving ineffective care. Many clinicians use a combination of strategies that—through their own experience, intuition, and judgment—work. But because their practices have not been studied in randomized trials, they are not proven as effective.²⁶

Although the scientific approach to testing strategies and practices has also shed some light on what may not work in children’s mental health care, many of these practices are still being implemented and reimbursed by health plans. For instance, experts now question whether a therapy known as “critical incident stress debriefing,” in which trauma victims are encouraged to describe and vent their emotions within one to three days of a traumatic incident, is more harmful than helpful. Group therapy may actually increase behavior problems among high-risk teens with conduct disorders. A number of experts believe that psychotherapy without stimulants does little to help children with ADHD. Children with severe emotional disturbance who are placed in group homes often get worse once they return to their own homes, yet group homes continue to be used and payments for them continue to be reimbursed.²⁷

In this nascent field of evidence-based treatment for children’s mental health, questions remain regarding the effectiveness of these strategies in real-world settings, such as clinics, schools, and providers’ offices. Studies of such treatment have typically been conducted in university laboratories, where patients are chosen with a particular set of problems, and providers possess a known set of skills and experience. Many experts caution that conditions are not as tidy in the real world. Patients often come to the clinical setting with multiple disorders as well as family problems, such as parents’ substance abuse. They may also terminate care early. In addition, providers may not strictly adhere to treatment strategies recommended in a manual, and more experienced providers may also resist new ways to treat their patients.²⁸

Not all agree that formalizing evidence-based care for children’s mental health is a good move. Some providers believe that if it becomes the standard in professional training and a condition for third party payment, it will restrict their creativity in finding the best ways to help their patients. Others fear that once treatment strategies are formalized, researchers and practitioners will have little incentive to improve on them.

But because this movement is so new, evidence-based measurements for children’s mental health care have not much affected managed care practice yet. “On evidence-based treatment, we’re just scratching the surface,” says Dr. Rhonda Robinson-Beale, chief medical officer for CIGNA Behavioral Health, which covers 14 million people. According to Dr. Beale, CIGNA examines the medication treatment plans for patients— adults and children—in inpatient psychiatric units, checking for cases in which the plan does not mesh with guidelines put out by the American Psychiatric Association.

Not all agree that formalizing evidence-based care for children’s mental health is a good move.

Dr. Richard Frank, health economics professor at Harvard Medical School, concurs that behavioral health organizations are starting to use evidence-based treatment measures in the area of medication management for conditions that have well-documented treatment practices. They are starting with strategies to ensure patients are not only prescribed the appropriate medication but that they are taking it.

Dr. Frank believes it is premature to try to implement a uniform standard for evidence-based psychotherapy. “Having it stew out there in the world a little bit longer might be a better thing,” he says.

Community-Based Systems of Care

Provider supply and effective care for children’s mental health take on broader meanings when applied to community-based systems of care for children with severe mental illnesses. Since the mid-1980s, the trend in caring for children with serious emotional disturbance has shifted the focus of care away from psychiatric hospitals and toward community-based care—day programs, respite care for families, therapeutic foster care, and home-based counseling to stabilize families and prevent a child’s institutionalization. States and the federal government have taken the lead in creating such systems of care, using substantial funds from the Substance Abuse and Mental Health Services Administration (SAMHSA) and Medicaid.

The trend in caring for children with serious emotional disturbance has shifted away from psychiatric hospitals, toward community-based care.

Public mental health systems for children across the states are experiencing workforce shortages. “There’s a cry from the children’s mental health directors in the states. They’re having a terrible time getting qualified people to come and work within the public sector,” says Joan Dodge, with the National Technical Assistance Center for Children’s Mental Health at Georgetown University. Ninety percent of states have reported difficulty in recruiting and retaining child welfare case workers,²⁹ and 21 state mental health agencies reported shortages of social workers in 2001.³⁰

A shortage of psychiatrists is particularly acute in the public mental health sector. Twenty-two state mental health authorities reported shortages of psychiatrists in state hospitals; 21 reported such shortages in community mental health programs. To deal with this, 25 states have allowed nonphysicians—a mix of nurse practitioners and physician assistants— to prescribe and/or monitor patients’ medications.³¹

Regarding effective systems of care, experts largely agree on what constitutes a quality system. For instance, systems that (a) are family-driven, (b) create care plans that incorporate parents’ needs, (c) are culturally and linguistically competent, (d) use case managers appropriately, and (e) employ staff who can work well across various agencies (schools, juvenile justice, child welfare, special education, public mental health) are considered quality systems.³²

A body of evidence-based care is also emerging for these systems of care. Among the findings, children released from institutions and placed in therapeutic foster care show better behavior and fewer rehospitalizations than those released to community care. One treatment showing extremely strong effects is multi-systemic therapy (MST). It is a short (3 to 4 month) program in which providers visit the home, sometimes daily, to improve not only the behavior of children who are at risk of entering the juvenile justice system but also the coping skills of family members. MST has significantly reduced out-of-home placements and arrests among these children.³³

But researchers note that workers in the public mental health system are largely ill-prepared to implement evidence-based care. “Rarely do professionals receive training in the values, skills and attitudes consistent with reforms that call for partnerships with families, cultural competence in service delivery, comprehensive cross agency interventions, individualized care and home and community-based approaches,” note the authors of a paper published by the National Technical Assistance Center.³⁴

A number of states are taking steps to remedy these training deficits. Pennsylvania has formed a training institute that is part of its Child and Adolescent Service System Program (CASSP), which, with federal support, offers community-based care for children with severe emotional disturbance. The institute has developed a set of core competencies for providing mental health care for children in the public CASSP system. These include best practice models for individual care, public systems management, and working with families. The goal is that continuing education programs for various system providers will contain these core competencies.³⁵ In similar fashion, the Maryland Department of Health and Mental Hygiene in spring 2004 convened a strategic planning session with multiple stakeholders to develop strategies for the recruitment, retention, and training of professionals and paraprofessionals who work with children with mental health needs and their families.³⁶

Although mental disorders are just as prevalent among minorities, they are less likely to seek care.

Serving Minorities

Culture—ethnicity, race, and shared norms and beliefs—has a distinct impact on mental health. It influences how patients manifest and communicate their symptoms, their willingness to seek treatment, and their networks of support, according to a 2001 surgeon general’s report.³⁷ The report found that, although mental disorders are just as prevalent within minority populations in the United States, minorities are less likely to seek care, and the care that they do receive is often of a lower quality than care provided to non-minorities.

Minority representation, as well as a knowledge of how to approach people of different cultures, is lacking in the mental health workforce. Although 12 percent of the U.S. population is black, only 2 percent of psychologists, 2 percent of psychiatrists, and 4 percent of social workers are black providers.³⁸ Moreover, there are only 29 Hispanic mental health professionals for every 100,000 Hispanics in the United States, compared with 173 non-Hispanic white providers per 100,000.

Minorities are also poorly represented in studies of evidence-based treatments, according to the surgeon general’s report. The surgeon general has called for targeted training funds to lure more minorities into the mental health professions, as well as greater participation of minorities in mental health research.

Actions being Taken

To improve the children’s mental health workforce supply and the practice of effective care, a number of actions are being taken in the public and private sectors.

Looking toward the Future

There have been dramatic shifts in the composition of the children’s mental health workforce, in the way that each discipline defines its role, and in the knowledge of talk therapies and medications that improve children’s mental health problems. Combined with the large demand for services, these changes have created more questions than answers about how services should be delivered, who should deliver them, and what interventions should be used.

Experts have offered a number of projections. One is that clinical social workers, in the future, may assume the role of today’s psychologists in providing extended psychotherapy. Psychologists, in turn, would provide the care typically offered now by psychiatrists (for example, prescribing and monitoring medication), and psychiatrists would become specialists in the biomedical aspects of mental illness. Richard Scheffler, a health economist at University of California, Berkeley, offered this scenario in a 2003 article that appeared in Health Affairs.⁴²

In the future, clinical social workers may assume the role of today’s psychologists in providing extended psychotherapy.

Another scenario is that the development of core competencies in children’s mental health may eventually erode the concept of separate disciplines (social work, counseling, psychology, psychiatry) in favor of skill sets. Dr. Ron Manderscheid, chief of the Survey and Analysis Branch of SAMHSA’s Center for Mental Health Services, posits that once a core set of requirements is developed, providers’ expertise would be distinguished by their mastery of serving a unique population, such as minority children, or those with serious emotional disturbance.

Some experts can already project the kinds of changes that evidence-based practices will require of the workforce. They are likely to call for additional training for specific procedures, such as MST, and a re-tooling of skills to practice strategies, such as cognitive-based therapy. New knowledge in SSRI treatment could require providers to manage their practices differently to keep close track of patients’ reactions to drugs, says Dr. Kelly Kelleher, director of the Office of Clinical Sciences at Children’s Research Institute in Ohio and professor of pediatrics at The Ohio State University.

Others acknowledge that evidence-based treatments, with their regimented manuals and practice guidelines, could allow providers without doctoral credentials (for example, clinical social workers or master’s level counselors) to have just as much of a chance of improving patient outcomes as psychologists. Two pioneers in this field, Dr. Kimberly Hoagwood at Columbia University and Dr. John Weisz at Harvard, note that the bulk of evidence-based talk therapies could conceivably be delivered by master’s level clinicians. This calls into question the need for providers with higher credentials to provide front-line mental health care.