The Challenge of Child and Youth Mental Health
MJH: A tremendous amount of work has been done in the last little while to bring the conversation about children's health to a much broader agenda. There's clearly a new dialogue unfolding in healthcare. However, when you think about children and children's mental health, what concerns come to mind in that arena, and why do you think we're facing challenges in the area of child and youth mental health?
MK: I think there are two or three principle reasons for these challenges. One reason is the views of parents. The stigma that's attached to all of mental health is particularly noticeable with respect to kids. There are surveys that show that 38% of Canadian parents would be too embarrassed to tell anyone if their child had a mental illness. Well, that's a pretty telling number. So right away you have the crisis caused, in part, by the fact that a significant number of kids aren't taken for help because of social stigma.
The second reason is that there is such a scarcity of resources in mental health. If you look at any of the most recent numbers, Canada is spending somewhere between 7 and 8% of its healthcare dollars on mental health. This is in comparison to 12% in most of the other major industrialized countries in the Organisation for Economic Co-operation and Development. Mental health, by any measure you want to use, is underfunded – both on the research side and on the service side.
In any case like that, children always get the short end of the stick because they're not in a position to lobby and argue for extra services or even for adequate services – and their parents won't say anything. So, you have a combination of social stigma and underfunding, a combination that really hurts kids.
MJH: When you're thinking about the work that you've done and you recognize that it is underfunded, do you see that as a significant problem in our day and age?
MK: It's a huge problem – although money is by no means the only issue. Nor can the problem be solved just by throwing money at it. We also have a huge human resource shortage across mental health. And everything that's true for mental health is true to an even greater extent for children's mental health; there are fewer people, there are fewer services and there is less funding.
Until we begin to deal with the entire system comprehensively, which is why the Mental Health Commission has been asked to create a national strategy, it will be very difficult to make systemic improvements. All the individual pieces need to be interlocking, and the situation for children is a good example of that. In many provinces, for example, the minute you turn 16 (or in some places 17), you move from being part of the children's system to being a part of the adult one. Many of the services you received as a child in the mental health system are not available to adults. It's almost as if, overnight, you're a different person and you get a different set of services.
There's no seamless transition here across a person's lifespan. And that's another big problem. If you think of youth – let's say, 16 to 24 – that's an age bracket that needs a huge amount of mental health services. But they are treated as adults and not as children. Therefore, they get not only a different range of services but a different volume of services than would otherwise be available. The lack of a seamless transition across age breaks creates a real problem.
The same thing occurs, by the way, at the other end of the spectrum, in the sense that there are certain things that are available to seniors that are not available to people who are not seniors. The most common example is pharmaceutical plans; the provinces run plans for seniors but not necessarily for other people. There's a significant problem, for example, when a 62-year-old is ineligible to have her antidepressants paid for, whereas if she were three years older, they would be covered. When you think about it, it doesn't make a lot of sense.
MJH: Thinking about children and youth in today's environment, would you comment a little on what you're seeing in terms of your work and who is most at risk? I would also like to hear your views on whether this is a growing problem or just one that we're becoming more aware of.
MK: I have two comments on that. First, it's a rapidly accelerating problem – not just for kids, but for everybody. But, again, the stresses and strains of being a teenager these days (compared with when I was a teenager, many years ago) are significantly greater for all kinds of reasons: there's peer pressure, there's education pressure, there's pressure from home and we have many more single-parent families. We also have many more children living in poverty or on the edge of poverty. All those problems existed in part in the past, but they are much worse now than they were, say, 50 or 60 years ago. Today, you have a whole lot more vulnerable children.
Canada has also become more multicultural and cosmopolitan. The problem is compounded by the fact that children are seeking and needing services that are culturally and linguistically appropriate for them, yet the reality is that virtually all the services we provide are in English or French. As opposed to some other types of health services, it is critically important in mental health to be able to operate in the language and the culture of the people you're dealing with.
MJH: You've been talking about children's mental health as a growing concern, and about the kinds of pressures and stresses youth face. Thinking long term, what do you see as the implications for society and the economy if we don't address those challenges today?
MK: First, if you stick strictly to the level of the individual, you'll find a whole lot of underserviced people who clearly need help. They will become adults with problems that have not been dealt with, and that raises economic problems.
Seventy percent of adults with mental illnesses had the onset of their illnesses when they were young. When people have mental illness that is not treated appropriately, they end up costing the state a lot of money. They need income support, they often end up in jail, they need supportive housing and so on. Not only do the individuals suffer because the problem wasn't treated properly, but society suffers both in terms of what's happening and because it has lost productive citizens.
The impact on public expenditures is also huge. Forgetting about the human side for a minute, it is much, much cheaper to simply treat children when they have their initial onset. Then, having done that, you can avoid a lot of expenditures down the road. But trying to get decision-makers to focus on making an investment in children's mental health so as to avoid long-term expenditures in the prison system, in social welfare and so on is a very difficult thing to do. It's hard to identify specific individuals who ended up in jail or on social assistance because they didn't get treatment. Yet, the reality is that the evidence is all around us that that's exactly what's happening.
MJH: What should we be doing from a policy perspective?
MK: That, of course, is what our national mental health strategy is all about. I can't, therefore, give you a definitive prescription now, but I think it is pretty clear that our strategy will focus on the need to increase significantly the number of services that are available to children and youth, to attack the stigma issue so that parents are willing to take children to get help when they need it and to restructure the system so that it is significantly more efficient.
On that last point, the current system is very much silo driven in the sense that each service is typically delivered by a series of not-for-profit agencies that are not systemically integrated. You need to change the way services are delivered, to get more people who can deliver them and to change the way funding is given. Even if you improve the delivery system by making it more efficient, you still need the people and the money to make it work. But, conversely, just getting the people and the money will not solve the problem. You must change the way the system operates.
MJH: One of the concerns I hear relates to the numerous reports that have been written about the state of children's mental health – or mental health in general – and the worry that we're putting a tremendous amount of effort into trying to understand the issues when many experts in the field say we already know what the issues are. We seem to be stuck in a quagmire: across the country there are creative examples of projects, tools and support systems, but they are not impactful enough to effect change.
So, how will we move on this agenda in a major way? Given that we have a policy framework and recommendations arising from the work that you're doing, what are some of the things that the providers of mental health services should be thinking about to keep this moving before we have the "big answer"?
MK: Well, first, there won't be one big answer. A whole lot of little pieces will make up the answer.
One of the things we will be doing is identifying best practices. The challenge in that process is getting people who are already inside the system to imagine themselves as external to it and to then offer objective advice about how they would alter the system. In other words, what the Mental Health Commission will need from people is information about what is precisely required to make the system work better – in a pragmatic sense. Nobody can provide that advice better than the people inside the system, but they're often reluctant to give you proposals that would require that they change the way they do things. I'm often fond of quoting Mark Twain's observation that "everyone is in favour of progress; it's just change they don't like." The hardest thing is to get people to be willing to be open-minded enough to talk about how they would or could do things differently to make the system operate better for patients as opposed to organizations. The system is very much organization driven, and people look at it in terms of whether it serves their organization or not. By the way, that's human nature, and I understand that. But we've got to get beyond that approach and focus on how we're going to build a patient-centred system. People should start to think about that issue because we are going to recommend a number of changes that, when taken together, will have a large impact.
My biggest fear is that objective, knowledgeable people will develop a way to restructure the system that isn't theoretical or academic but that will collide with people's willingness to embrace change in everything but themselves. Now, I'm hoping that if that happens, governments will have the fortitude to ride over those changes as they did with a lot of the things the Senate Committee proposed in 2002 when we developed the acute care report. A lot of the more controversial recommendations we made in that report are in fact being implemented by governments because, in some sense, they have simply blamed the people who wrote the report. I frankly think that one of the roles of the commission will be to take some of the flak by allowing governments to sort of say, "Look, we're going to do what the commission says. So, if you don't like the changes, blame the commission. Don't blame us." I believe that's a reasonable role for an outside third party like us to play.
MJH: You spoke earlier about the need to get at some of the challenges and issues early on so that we're operating in a prevention mode – at least, prevention of some of the most acute types of mental health challenges. In that regard, having a health system that's focused on early-years, long-term prevention is critical.
Would you leave us with some encouraging words on how you "think big" while you're taking small steps, and on how you keep your eye on the ultimate vision for child and youth mental health? What is your vision of excellence for the mental health system for children and youth in Canada?
MK: My vision is that public attitudes will shift so much that parents won't feel stigmatized and discriminated against if their children need mental health help. I look toward a day when parents will be willing to seek help and to talk about their children's situations as openly as if they had cancer. Realizing that vision requires changing both public attitudes and behaviours.
I also have a vision of a seamless system that enables a child with a mental illness to be treated quickly. Young people may have to live with mental illness for the rest of their life, but if they receive early treatment, they'll be perfectly good and productive citizens. When I think about "recovery" in terms of mental illness, I liken the situation to people who have diabetes: individuals who manage to live with their illness for their entire life. People with mental illnesses can do the same thing. But getting to that point is going to require a sea change in public attitudes and in the attitudes of people who are delivering healthcare services.
I'm optimistic, not because I'm naive but because I believe there's a groundswell happening right now. Everywhere I go in Canada, I detect growing support for changing and improving mental health services. That fact makes me optimistic that the combination of really good knowledge of the right things that need to be done and the Mental Health Commission's development of a powerful social movement in support of system change will, given the current climate and attitudes, bring about huge transformation.
MJH: I share your optimism. Everywhere I've been across the country, mental health is always first on the list of the top three challenges facing children and youth.
MK: Absolutely. And I'll give you another good reason to be optimistic: When I started in healthcare with the Senate Committee in 2000, if you had asked provincial or territorial health ministers anywhere in the country what their top three priorities were, mental health – in general or for kids – would never, ever have been listed. If you were to ask that same question to any health minsters today, they would all put mental health in their top three, and many would put it at the very top.
Now, you might ask, "What difference does that make?" What it tells you is that a whole lot of people are now looking at this issue in a way they weren't less than a decade ago. As you know, it takes a long time to change attitudes in big organizations. We're coming across fertile ground at the present moment. The role of the Mental Health Commission and of people in mental health services is to capitalize on that opportunity so that we can get the kind of support that's required to make the changes that we really need.
MJH: I believe we owe it to the groundswell of public optimism to make sure we have an impact over the next generation.
MK: That's exactly right. That's exactly what we have to do. I keep saying to people working in the system, "Look, very seldom in life do you have an opportunity to really make a difference. But now is one of those times." I think that there's now a whole confluence of events that makes change possible at this particular point in time. I hope that everyone pitches in to make it work.
MJH: Terrific, Michael. Thank you.
About the Author
Mary Jo Haddad, Chief executive officer of The Hospital for Sick Children (SickKids), Toronto, Ontario, had a chance to sit down and chat with Michael Kirby about the challenge of children's mental health.
Michael Kirby, Chair of the Mental Health Commission of Canada. Born in Montreal, Quebec, in 1941, Kirby obtained his MA in mathematics from Dalhousie University and his PhD in applied mathematics from Northwestern University. In 1984, he was appointed to the Senate of Canada, a position he held for 22 years. From 1999 to 2006, Kirby chaired the Standing Senate Committee on Social Affairs, Science and Technology, which, under his leadership, the produced the first-ever national report on mental health, mental illness and addiction.
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