The Editor's Letter
This second instalment in our Child Health in Canada series explores a multi-faceted topic that weighs especially heavy on the minds of parents, teachers, care providers, policy makers, social workers and many others: mental health. After all, as Stan Kutcher asserts in his contribution to this issue, "there can be no health without mental health."
The mental well-being of our children and youth is a major cause for concern. In Ontario, for instance, half a million children grapple with mental health problems (Children's Mental Health Ontario [CMHO] 2010a). A recent study in the United States similarly revealed that approximately one in five young people in that country – the same proportion as in Ontario (CMHO 2010a) – suffer from a "mental disorder" that is severe enough to undermine their normal functioning (National Institute of Mental Health 2010, September 27). The consequences of leaving such problems untreated include school failure, family conflict, drug abuse, violence and suicide (CMHO 2010b). And we should never forget that mental health problems among the young are not neatly confined to the early years: 70% of Canadian adults who have mental health issues developed symptoms before age 18 (Mental Health Commission of Canada [MHCC] 2010).
Where Are We with Child and Youth Mental Health? Where Do We Need to Go?
Issue one of this Child Health in Canada series concluded with an interview I conducted with Michael Kirby, the chair of MHCC. That dialogue set the stage for many of the discussions you will encounter here, including the effects on young people of mental health–related policies, services, funding, treatment models and public perceptions.
Our first essay is by Simon Davidson. Like his MHCC colleague Kirby, Davidson takes a strong stand on the need for improved mental health services for children and youth. Even though mental health disorders are widespread, "child and youth mental health services continue to be significantly less resourced than physical health services and seriously fragmented at all levels," states Davidson. The relative lack of evidence-informed practices in child and youth mental health, he notes, compounds those problems.
Nevertheless, Davidson sees "pockets of excellence and reasons for optimism." Among the reasons for feeling positive is MHCC's Evergreen framework, which governments will soon be able to use when creating policy frameworks tailored to young people. MHCC is also developing a compendium of best practices in school-based mental health and addictions services, has prioritized working with youth and healthcare providers to reduce stigma and discrimination, is locating best practices for multi-stakeholder knowledge exchange and has struck an MHCC Youth Council. Beneficial developments occurring outside MHCC include the child and youth mental health policy frameworks in certain provinces and Ontario's Provincial Centre of Excellence for Child and Youth Mental Health. Davidson concludes with a list of elements that, he argues, would characterize a sustainable system of child and youth mental health care, including involving young people in developing their own care plans and the overall system, ensuring consumer-driven services that are provided when and where they are needed and fostering an integrated system that prioritizes care continuity.
The kind of "transformational change" Davidson envisions is echoed loudly in Stan Kutcher's essay. Taking a wide view of the matter, Kutcher asserts that mental health care for children and youth "is a point where human rights, human well-being, best evidence arising from best research, economic development and the growth of civic society intersect." At present, however, Kutcher sees a troubling gap at that intersection: "the availability of appropriate mental health care for children and youth in Canada does not come close to meeting the need."
Attributing that chasm largely to the "pernicious" historical reality that entails the provision of mental health care through a "parallel health system," Kutcher argues that this silo approach to care does not work: it neither provides the kind of "holistic" care youth and their families need nor facilitates access to best evidence. Whereas Davidson's suggestions for change are located primarily at the provincial/territorial level, Kutcher urges a national approach, which could involve, for example, creating a federal commissioner or minister of state for child and youth health.
Challenges within the System
Having set up various high-level concerns, we next shift to explorations of particular challenges affecting Canada's mental health system. Ene Underwood starts us off with a portrait of a high-risk youth – "Kayley" – whose mental health needs stem from childhood abuse and neglect. Underwood uses the story of Kayley and four other "vulnerable" children to illustrate the complex roles of child welfare agents in dealing with mental health issues and as background for proposing four strategies that address prevention and intervention, supportive transitions back to the community, supportive transitions between the youth and adult systems and stronger service-delivery integration.
Better youth-to-adult transitions and more robust integration are recurrent themes throughout this collection. They figure prominently, for example, in the contribution by Melissa Vloet, Simon Davidson and Mario Cappelli, which addresses "effective transitional pathways" from child and youth to adult mental health systems and services. The team's research led them to the conclusion that the Shared Management Framework is "the most feasible model of service delivery," one that "could easily translate to mental health care in Canada." Discussing their findings with a wide range of Ontario government officials, the team was able to draw on policy makers' perspectives in order to produce recommendations that address transitions at both the policy and practice levels.
One of the strongest points Kirby made when I interviewed him was that Canadians need to erase the stigma associated with mental health disorders. Heather Stuart, Michelle Koller, Romie Christie and Mike Pietrus tackle that thorny subject in their article, which presents findings from an MHCC Opening Minds educational symposium targeted at journalism students. This contact-based intervention had a significant impact on students' perceptions, an important result when one considers the role journalists can play in shaping public attitudes toward mental health.
Child and Youth Mental Health in the Community
Michael Chandler opens our community-focused section with a passionately argued piece that advocates a "radical reframing" of the topic of mental health among Indigenous Canadians. Committed to challenging normative ways of conceiving and discussing mental health issues, Chandler points out that wholesale accounts of problems among Indigenous people are unable to accurately represent the complexities and differences that exist within and among the country's more than 600 culturally distinct First Nations bands. Instead of "empty abstractions," he states, we need "fine-grained analyses." Chandler's second argument aligns with this emphasis on local specificity: we must, he urges, tap "Indigenous knowledge" if we hope to deal successfully with their issues of well-being. In Chandler's discussion of suicide and suicide prevention among British Columbia's Indigenous communities, I think you will find his "lateral transfer" approach at the very least intriguing and, I suspect, even highly persuasive.
Geographical remoteness, steep costs and the concentration of psychiatrists and other mental health care providers in urban centres demands creative solutions for dealing with mental health problems among children and youth living in rural communities (including many Indigenous Canadians). A particularly powerful solution is discussed in the article by a group of researchers affiliated with The Hospital for Sick Children; Antonio Pignatiello and co-authors address the benefits of the TeleLink Mental Health Program. This telepsychiatry program provides remote Ontario communities with timely, equitable access to specialist clinical services. While not a perfect modality, it currently serves a valuable function and, the authors conclude, illuminates telepsychiatry's "requisite components" and points the way to more sophisticated developments.
Our next essay examines "community" in the context of a justice system that needs to do much more in terms of understanding and supporting young people who commit crimes. Key to this, Alan Leschied argues, is an appreciation of the significant extent to which mental health disorders factor into youths' criminal activities. Echoing many of the observations made by other contributors around stigma, resource scarcity and lack of service coordination, Leschied propounds six mental health–focused strategies aimed at both reducing risk for young people and increasing community safety.
The public's generally unsympathetic view of young offenders largely stems, Leschied believes, from a lack of awareness of the deep connection between mental health disorders and criminality. A related knowledge gap might be present in the public's attitudes toward street-involved youth, the subject of Elizabeth McCay's article. Overlapping with many of the family-dysfunction and foster-care dislocations addressed by Underwood, McCay's article starts from the well-documented finding that "mental health challenges are ubiquitous to youth who are street involved." McCay's explanation of the causes of mental disorders in this population is awfully bleak. I was surprised, therefore, to learn of the "resilience" McCay and others have discovered among these individuals. Taking that resilience as a sign of the potential for healing, McCay advocates for more research on evidence-based interventions specific to this population, as well as for bold policies that support early intervention.
Over the past several years, Canadian media have reported extensively on the disturbingly widespread incidence of bullying among children and youth. In our next article, frequent media commentator Debra Pepler and three of her colleagues urge us to understand bullying as a "destructive relationship problem," one that poses risks for physical and psychosocial health – both for those being bullied and, I was somewhat surprised to learn, for the bullies themselves. In addition to providing a review of the extensive literature on bullying and its effects, the authors urge healthcare professionals to act on their moral duty to screen for and report all signs of bullying behaviour and "peer victimization."
One of the most pervasive efforts to curb bullying, aggression and violence among Canadian young people is Roots of Empathy (ROE). Although widely implemented, ROE has rarely been evaluated. Rob Santos and four co-investigators examined ROE's "real-world effectiveness" among students in Manitoba. Their findings indicate significant violence-reduction benefits, outcomes that potentially last up to three years following program completion. Given the call by several of the contributors (e.g., Davidson, Chandler and McCay) to this issue of Child Health in Canada for evidence-based child and youth–focused mental health strategies, these prevention-focused results warrant a good deal of attention.
Much in this issue of Child Health in Canada might well leave you feeling daunted by the enormity of the organizational, political, clinical, financial and social challenges we face. If that is the case, I urge you to take an extra 10 minutes to read the concluding interview Gail Donner conducted with Karen Minden, one of the founders and the first chief executive officer of the Pine River Institute. Minden's work in establishing Pine River and ensuring its effectiveness in helping young people overcome their mental health and addiction problems is a model of intelligence and devotion that will, I am confident, inspire you to re-double your own efforts.
Before I turn this issue over to you, however, I want briefly to thank the authors of the essays for their remarkable support. Longwoods's editorial director Dianne Foster Kent and I have rarely before met with such an enthusiastic response to invitations to contribute. We believe that our authors' eagerness demonstrates the deep commitment this varied community of care providers, researchers, policy makers and administrators has for advancing the mental well-being of children and youth.
About the Author
Mary Jo Haddad, RN, BScN, MHSc, LLD, CM, President and Chief Executive Officer, The Hospital for Sick Children, Toronto, Ontario
Children's Mental Health Ontario. 2010a. Annual Report 2010. Toronto, ON: Author. Retrieved February 18, 2011. <http://www.kidsmentalhealth.ca/documents/res_cmho_annual_report_2010.pdf>.
Children's Mental Health Ontario. 2010b. Children's Mental Health Week Is Just around the Corner! Toronto, ON: Author. Retrieved February 18, 2011. <http://www.kidsmentalhealth.ca/news_and_events/CMHW_2010.php>.
Mental Health Commission of Canada. 2010. On Our Way: Mental Health Commission of Canada Annual Report 2009–2010. Calgary, AB: Author. Retrieved February 18, 2011. <http://www.mentalhealthcommission.ca/annualreport>.
National Institute of Mental Health. 2010, September 27. National Survey Confirms That Youth Are Disproportionately Affected by Mental Disorders. Rockville, MD: Author. Retrieved February 18, 2011. <http://www.nimh.nih.gov/science-news/2010/national-survey-confirms-that-youth-are-disproportionately-affected-by-mental-disorders.shtml>.
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