’
Pediatric Community Mental Health
Lisa M. Cullins, MD, Mary Gabriel, MD, Martine Solages, MD,
David Call, MD, Shalice McKnight, DO, Milangel Concepcion, MD,
and Jang Cho, MD
The emotional health and wellbeing of children and adolescents
and their families is of utmost importance. Pediatricians are at the
front line in identifying mental illness in children and adolescents
and either linking them to resources in the community or providing
treatment options themselves. Collaboration and integrative
Introduction: Defining the Need,
Evolution and Core Attributes of
Effective Pediatric Community Mental
Health
pproximately one in five children in the United
A States suffers from a diagnosable mental dis-
order at an annual cost of $247 billion.1
Overall, 70–72% of children and adolescents who are
in need of treatment do not receive mental health services.
Thus, the actual cost of mental health care for children
and adolescents is potentially much greater. Of those who
seek treatment, only one in five children use mental
health specialty services. The vast majority of these
children receive treatment from their primary care
physicians. A child waits an average of 8–10 years
between onset of symptoms and receiving treatment,
primarily due to a lack of access to services. For the
families that seek services, 40–50% terminate treatment
prematurely secondary to lack of access, lack of trans-
portation, financial constraints, child mental health pro-
fessional shortages and stigma related to mental health
disorders.2 In sum, most children and adolescents with
mental illness do not receive treatment for their symp-
toms. The treatment gap is even more profound for
anxiety disorders and substance abuse. The gap widens
even further for racial and ethnic minorities with Hispanic
and African American adolescents with mood disorders
From the Children’s National Medical Center, Washington, DC 20010.
Curr Probl Pediatr Adolesc Health Care 2016;46:354-388
1538-5442/$ - see front matter
& 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.cppeds.2016.09.001
354
health care models is the cornerstone of effective strategies to
provide access and quality mental health care to children and
families in communities across the country.
Curr Probl Pediatr Adolesc Health Care 2016;46:354-388
in particular being less likely than their Caucasian peers to
receive treatment.3 Research has shown that without treat-
ment, these childhood disorders may persist and lead to
school failure, poor employment opportunities and poverty
in adulthood, and even more tragic outcomes—suicide.
The data is even more staggering for children and
adolescents who are publically insured, and/or ethnic
minority youth. Presently, Medicaid is the largest
payer of mental health care in the United States and
disproportionately serves individuals with the most
severe mental disorders. Most of the expenditure is
accounted for by multiple or extended out-of-home
placements not community outpatient settings.1 Facili-
ties that provide specialty outpatient mental health
services and accept Medicaid comprise the backbone
of the community-based treatment infrastructure for
Medicaid enrollees.4 However, more than a third of the
counties in the US do not have any outpatient mental
health facilities that accept Medicaid. Furthermore,
communities with a larger percentage of residents
who are Black, Hispanic, or living in a rural area are
more likely to lack these facilities.5 With the Affordable
Care Act, more individuals will be able to receive access
and quality mental health care as mental health and
substance abuse disorders have been designated essential
health benefits. It is estimated that by 2019, this type of
Medicaid program expansion nationwide would double
the number of persons with mental disorders who are
covered by Medicaid from 12.8% to 24.5%.4
The potential expansion to improve access to and
quality of mental health care in participating states
requires an adequate supply of mental health profes-
sionals who accept Medicaid. Although the majority of
Curr Probl Pediatr Adolesc Health Care, November 2016
psychiatrists practice in solo or group office settings
(51%), only 3% and 8% of patient caseloads in these
settings are covered by Medicaid, respectively.4 For
child and adolescent psychiatrists in particular the
numbers are even more daunting. It is estimated that
to meet the mental health needs of children and
adolescents in the US, 30,000 child and adolescent
psychiatrists are required and approximately only 9000
are present.6 Mental health providers who participate
in Medicaid tend to be concentrated in hospital and
specialty community-based mental health clinic
settings.4
The beauty and essence of pediatric community
mental health is to serve children and families who
are impacted the most by poverty, meager educational
and employment opportunities, poor resources and
violence in their communities in locations that are
either close to or embedded in their neighborhoods.
The impassioned spirit and charge of pediatric com-
munity mental health is ever present, and its signifi-
cance and sense of urgency is palpable, but the
infrastructure in which to implement and deliver
services is fragile and unstable and gravely inadequate
to meet the basic mental health needs of children and
adolescents and their families.
Evolution of a System: Community-Based
Pediatric Mental Health
An important concept in the evolution of care
delivery in children’s mental health emerged as child-
ren’s mental health was better understood, but did not
resemble the modern system until the 1990s. This
concept, community systems of care, reflected the
emerging appreciation of the complexity of the devel-
opment of children and demonstrated an attempt to
address this complexity more thoroughly and thought-
fully. It was not until the last 2–3 decades; however,
that this approach was formalized and resembled the
current framework of care delivery. This model now
represents the standard of care for public mental health
services.
Coordination of services is essential for all children,
but even more important for those children with severe
emotional disturbances and involvement of multiple
agencies. The community systems of care model,
based on principals of the Child and Adolescent
Service System Program (CASSP),7 was developed
to coordinate and integrate care from these different
systems for children with complex mental health needs
Curr Probl PediatrAdolesc Health Care, November 2016
and to provide each child and their family individu-
alized and culturally competent services within the
community. The need for such coordination arose from
the increasing influences of policy and advocacy that
resulted in the de-institutionalization of mental health
care in the 1960s. The Community Mental Health
Centers (CMHC) Act of 19638 introduced stronger
federal involvement in mental health care, responsibil-
ities that until then were seen as mostly residing with
states and, to a lesser extent, local communities. After
6 years, however, the Joint Commission on Children’s
Mental Health9 found that despite this infusion of
federal funding, little national attention or resource was
dedicated to children and their families and that too
many children were receiving grossly inadequate and
inappropriate mental health services. In response, the
CMHC Act was extended in 1972, directing commun-
ity mental health centers to expand their responsibil-
ities to include services for children. After 10 years,
however, a study published by the Children’s Defense
Fund documented that children with serious mental
and emotional disorders were receiving care that was
fragmented, uncoordinated, and largely ineffective,
often in institutions far from their homes.10 Such
findings prompted the National Institutes of Mental
Health to establish the CASSP in 1984, heralding the
inception of what is now known as community systems
of care. Two more milestones set the stage for CASSP:
the President’s Commission on Mental Health in
1978,11 which helped children and adolescents with
severe emotional disturbances become designated as a
priority service population; and the Alcohol, Drug
Abuse, and Mental Health Block Grant program12 in
the 1980s instituting joint federal and state funding
with a formula stipulating that 25% of funding be
dedicated to children and adolescents.
Changes in service design and delivery were required
once the framework was developed. Multiple demon-
stration projects were initiated to restructure care
delivery and actualize the principles on which the
framework was founded. Five pilot programs were
launched in Ventura County, California,13 Alaska,
Vermont,14 the Fort Bragg Demonstration Project,
and the Robert Wood Johnson/Mental Health Services
Program for Youth (eight sites). The aims of these
programs were to implement CASSP ideals, reduce
out-of-home placements, reduce service fragmentation,
and promote earlier mental health intervention to
reduce functional morbidity. Modern health economics
now reinforces the goal of preserving children in their
355
communities, namely by focusing decreasing the
utilization of highly restrictive and expensive services.
With this background in mind, a comprehensive
understanding of community systems of care is possi-
ble. Children develop and function within multiple
systems, consisting of their families, schools, com-
munities, and primary health care. Children with emo-
tional and behavioral problems engage in additional
systems to access care and services, including mental
health, special education, developmental disabilities,
child welfare, and juvenile justice. Moreover, mental
health concerns interact with multiple co-existing
social, cultural, and legal issues, making work with
these populations complex and challenging. Studies in
best practices, quality of care, and outcomes spurred on
the evolution of a framework that outlined core values
and guiding principles for a system that would meet the
complex needs of these children and their families. The
culmination of that framework was the CASSP. Its
guiding principles consist of the following: (1) indi-
vidualized care that is tailored to the individual needs
and preferences of the child and family, (2) family
inclusion at every level of the clinical process and
system development, (3) collaboration between differ-
ent child-serving agencies and integration of services
across agencies, (4) provision of culturally competent
services, (5) to serve youths in their communities, or
the least restrictive setting that meets their clinical
needs through providing a continuum of formal treat-
ment and community-based supports, such as respite,
crisis shelter care, mentoring, (6) early identification
and intervention, and (7) transitions to adult services.
Using these principles, the goal of systems of care is
to increase the number of children who are “in home, at
school, and out of trouble.” To actualize these princi-
ples and achieve this goal, a successful system of care
is characterized by the following: clinical services are
accessible and available in community settings, such as
schools, youth centers, and homes; services are organ-
ized as collaborative ventures with other child-serving
agencies, such as child welfare, probation, special
education, developmental disability, and health; con-
sumer empowerment and responsibility (family and
youth “voice and choice”) is reinforced with
“strengths-based” approaches in treatment planning
and service delivery—care is congruent with family
values and goals, merging wraparound supports and
services with traditional mental health interventions;
clinical outreach and case management are central
elements of service delivery, seeking to match family
356
needs and strengths with community-based supports—
paraprofessional mental health staff, without licensure,
and community and family volunteers work as mentors
with youth and their families, pursuant to individu-
alized service plans and clinical oversight; child
psychiatric and other mental health professional
involvement is supported to ensure needed clinical
assessment and treatment interventions; and local
public and human service agencies collaborate in
integrating mental health services in their operational
planning and funding considerations.15
The core components of the model are two-fold—its
reliance on wraparound approach for supporting youth
and families to succeed in community care and its use
of integrative interagency practices among relevant
child-serving systems.16 These elements are particu-
larly salient, given that public mental health programs
give priority to those who, in addition to not having
access to care due to socioeconomic challenges, are
involved in other public systems serving children,
including child welfare, juvenile justice, special edu-
cation, developmental disabilities, and substance
abuse. While integration of care between entities is
familiar to most medical professionals, the notion of
the wraparound process, the quintessence of consumer-
directed care in children’s mental health, may not be.
The wraparound process is an integrated assessment
and planning process that results in a unique set of
community services and natural supports that are
individualized for a child and family to achieve a
positive set of outcomes.17 It focuses on child and
family strengths; it is community-based, culturally
relevant, flexible, and coordinated across agencies;
and provides unconditional care, which entails a
commitment to doing what is needed over the long
run rather than ejecting a child from service if the
needs are not being met.18 The fundamental goal of
wraparound services involves empowering families to
build on strengths and capacities to overcome chal-
lenges to the adaptive well-being of their children so
that they can achieve greater self-sufficiency. Child
and family teams are used in a wraparound process as
the nidus of service-planning and decision-making.
The teams are composed of the child, his or her family,
and any other friends or family members chosen by the
family as well as all of the mental health or other
agency providers that are involved with the child. The
clinical approach is one that is strengths based,
assessing the child and his/her family in terms of
adaptive capacities rather than pathology. Evaluating
Curr Probl Pediatr Adolesc Health Care, November 2016
the child in the context of the systems he or she exists
in (family, school, community cultural institutions, and
primary health care) allows for the discovery of
environmental and systems factors contributing to their
current functioning. Such evaluation generates an
ecological picture of the environment in which the
child is developing and functioning and emphasizes the
idea that the parent’s knowledge of their child, family,
and culture is valued equally in importance to the
clinician’s knowledge of child development and psy-
chopathology. This facilitates more extensive collabo-
ration between families and clinical members of the
team, allowing families to assume the natural functions
of case management and self-advocacy.19 When
strengths and culture exploration are at the crux of
assessment, treatment services and supports are chosen
to best suit the family’s objectives and maximize
collaboration toward desired goals.
Services are then provided to enhance the child or
family’s adaptive strengths, build self-esteem, and
provide opportunities for successful experiences.20
These services comprise a spectrum of supports,
education, and treatment, including intensive home-
based services (e.g., counseling, skill building, and case
management), mentoring service, respite services, and
flexible funds, all with the goal to most effectively meet
the child’s and family’s needs in multiple domains of
life and functioning. These services are actively coor-
dinated with interventions by other providers, including
primary care providers, other social agencies, and
community supports. Such interventions go beyond
direct treatment services, and include advocacy, facil-
itating communication among providers, and providing
consultation to the various clinical players and stake-
holders on the team. Unfortunately, there is variability
from state to state regarding the availability and quality
of wraparound as a service delivery model.
One critical issue to consider in evaluation and
treatment of child and their families is cultural sensi-
tivity and competence. Over 1/3 of all children in the
United States are from non-European racial and ethnic
backgrounds and is projected to exceed 50% by 2030.
This segment of the population faces many disadvan-
tages, including socioeconomic and educational dis-
parities, social discrimination, language barriers, and
lesser opportunities. Their different beliefs, values,
normative expectations for development and adaptive
behaviors, parenting practices, relationship and family
patterns, symptomatic expressions of distress, and
explanations of mental illness21 become a barrier when
Curr Probl PediatrAdolesc Health Care, November 2016
failure to meet their culturally informed needs leads to
increasing mental health disparities in already-
vulnerable populations. These disparities include
access to community-based services, accurate diagnos-
tic assessment, access to evidence-based interventions,
increasing rates of various psychopathologies, and
significantly higher rates of out-of-home placements
and juvenile justice.22 Such findings impress the need
for culturally competent services that address the
mental health needs of diverse populations, including
ethnopsychopharmacology.
In what may seem to be complete anathema to
traditional paternalistic approaches to care, in pediatric
community systems of care the family selects treatment
objectives and drives the planning process. This is a
challenge for provider-centric orientations to practice,
which are based on provider’s professional expertise.
Allowing families who are struggling in caring for their
children to have a leadership role in treatment proc-
esses appears incongruous with desired outcomes.
However, it is precisely because clinical understanding
of each case is established in the context of the child’s
and family’s lived experience, defined by the family
and demonstrated in the family’s culture and life
history, that the model is successful, as revealed by
multiple quality and outcome studies.
Core Attributes of Effective Comprehensive
Mental Health for Children
A comprehensive, effective mental health care sys-
tem of services for all children and adolescents should
be strength based and child and family centered. It
should have prevention as a primary component in
addition to services that address different levels of
acuity from least restrictive to most restrictive. It
should also utilize an approach that meets the family
where they are and attempts to sustain the child in their
natural setting (at home and in the community) when
clinically appropriate. Collaboration and care coordi-
nation should be its cornerstone as families have
multiple needs and services should be individualized
to meet those needs. Thus, as a child moves through
different levels of care and/or requires a variety of
services effective communication and collaboration
through the system of care is essential. Lastly, pro-
viders should be highly skilled, culturally competent
clinicians, well versed in evidence-based treatment
modalities, and have a greater understanding of the
unique experiences and stressors that families in
357
underserved communities in particular may confront
each day that may ultimately affect their children’s
emotional and social well-being.
The service continuum should include prevention,
early identification and comprehensive treatment serv-
ices ranging from high fidelity wraparound services to
individual and family therapy and medication manage-
ment. When clinically appropriate families should have
access to psychiatric inpatient units, partial hospital-
ization and residential treatment.
Despite the devastating numbers that still persist in
regard to the unmet mental health needs of children
and adolescents and their families, substantial, mean-
ingful work has been done over the past 20 years to
develop, implement and examine service delivery
models and sustainable funding streams that can
provide comprehensive, effective mental health care
with positive treatment outcomes. The challenge is
scaling and infiltrating these effective service
delivery models and funding infrastructure to all
states and counties not just the handful that currently
exist. The following service delivery models do exist
but are not widespread throughout the US and are
rarely implemented together as a full continuum of
care.
1. Prevention
(a) An important element of prevention is early
identification, which can begin during the
prenatal period. Prenatally there should be
routine screenings for maternal depression
during medical visits, parenting classes should
be offered during this time. At birth, these
families should have access to home visiting
programs which promote positive parent–
child relationships and healthy child develop-
ment. There should be ongoing screening for
maternal depression during pediatric well-
child visits and follow-up post-partum visits
with OB/GYN. At pre-school age, there
should be mental health consultation and
intervention services provided for pre-school
and child care programs. Basic mental health
screenings should be implemented during
pediatric well-child visits; and if there is a
positive screen, the child and family should be
referred for a comprehensive assessment by a
mental health clinician; and if clinically indi-
cated, referred to programs such as Head Start
and Incredible Years.23
358
2. Treatment services
(a) In order to identify a child, who may need brief
or long-term mental health treatment a com-
prehensive assessment must be completed.
There are several portals through which a child
may pass for this to be accomplished. For
urgent or emergent situations, a child may be
assessed through the emergency room by a
mental health clinician or a mobile crisis team.
In a recent joint report from Substance Abuse
and Mental Health Services Administration
(SAMHSA) and Center for Medicaid & CHIP
services (CMCS), mobile crisis and stabiliza-
tion services have been instrumental in defus-
ing and de-escalating difficult mental health
situations and preventing unnecessary out-of-
home placements, hospitalizations in particu-
lar.24 For non-urgent situations, assessments
are usually conducted in an outpatient clinic
setting. School-based mental health programs
have demonstrated a long history of efficacy in
producing positive educational, emotional, and
social outcomes for children and families.
Thus, ongoing mental health consultation and
intervention services should be provided in the
elementary, middle- and high-school educa-
tional levels. In addition, child psychiatrists
should also provide consultation services to
pediatric subspecialists to assess and provide
treatment recommendations for children in
primary care settings.
(b) Once a comprehensive assessment has been
completed a treatment plan can be developed.
Level of care must be determined. For high
acuity levels, inpatient hospitalization, partial
hospitalization, and residential (for chronic
debilitating illness and repeat hospitaliza-
tions) should be considered. If outpatient
treatment is determined to be appropriate
then there is an array of services that should
be available which include high-fidelity
wraparound services that include flex funds,
intensive in-home services, individual, fam-
ily, and group therapy and psychopharmaco-
therapy.24 Treatment modalities should be
evidenced based, which should include cog-
nitive behavioral therapy, trauma-focused
cognitive behavioral therapy, behavioral ther-
apy, parenting skills training, and dialectical
behavioral therapy for adolescents. Clinicians
Curr Probl Pediatr Adolesc Health Care, November 2016
 should be able to address issues regarding
attachment, separation and loss, grief and
bereavement, social skills, adaptive coping
skills, and skill building. For co-occurring
disorders, adolescents should be referred for
appropriate substance abuse treatment that
includes both individual and family work.
Throughout all levels of care, peer and family
support services should be automatically linked
with services. Providers of peer and family
support services are family members or youth
with “lived experience” who have personally
faced the challenges of coping with serious
mental health conditions either as a consumer
or as a caregiver.24 In addition, in order to
prevent out-of-home placements, respite serv-
ices should be available for at-risk families.
(c) Ongoing training, consultation/supervision for
providers must be provided and embedded
into the service delivery model to meet basic
standard of care for evidence-based practices.
(d) Cultural sensitivity and competence is also a
measure that must be met for all treatment
providers caring for youth and families.
(e) Outcome measures for all services provided
must also be a component of the service delivery
model. Instruments such as the Child and
Adolescent Functioning Assessment Scale
(CAFAS), Child and Adolescent Needs and
Strengths (CANS), and Child Behavioral Check-
list (CBCL), for example, should be considered
for outcome measures at certain intervals during
the course of treatment and thereafter.24
In recent studies, the abovementioned mental health
services have demonstrated a positive impact for children
and families receiving Medicaid in the following areas:
reduced costs of care, improved school attendance and
performance, increase in behavioral and emotional
strengths, improved clinical and functional outcomes, more
stable living situations, improved attendance at work for
caregivers, reduced suicide attempts, and decreased contact
with law enforcement.24
The use of technology is another form of innovation
and service delivery model that must be considered in
meeting the mental health needs of children and
adolescents and nicely compliments both traditional “in
the office” services and integrated models in the pediatric
medical home and schools (i.e., Teleconferencing for
consultation, in-service teaching and direct care).25
Curr Probl PediatrAdolesc Health Care, November 2016
Telepsychiatry has demonstrated that it can improve
both access and quality of care. A recent study revealed
that telepsychiatry increased access to mental health care
and both practitioners and youth/parents report satisfac-
tion with the services.26 When telepsychiatry was
compared to direct face-to-face services, 96% of the
diagnoses and treatment recommendations were compa-
rable between service delivery models with comparable
patient satisfaction.27 Studies have even shown that
children and adolescents in particular report enjoying
the “virtual” experience more stating that is was “excit-
ing”—more visual, video game like, and less threat-
ening. Even in children aged 4–12 years, 94% like
videoconferencing with 29% actually preferring a “tele-
vision” doctor.28 In addition to improving access to care
and children and families actually enjoying this type of
service delivery model, telepsychiatry has also shown to
be cost-effective. With the advances in technology, given
the minimal start up equipment costs coupled with
numerous “deliverables” (i.e., enhanced clinical capacity
of rural practitioners, improved clinical expertise and
collaboration, increased access to specialty care,
decreased travel costs), telepsychiatry has demonstrated
on average a 70% reduction of costs.26,29 The Arizona
Telemedicine Program which serves 10 rural prisons
reported a savings of more than $1 million dollars.26
Evidence-Based Treatment Modalities
Evidenced-based treatments offer problem-focused,
time-limited, and symptom reduction psychotherapy.
There are now numerous efficacious evidenced-based
treatment modalities being implemented once the
treatment plan has been determined for a child or
adolescent. They range from individual work with the
child to family systems work or a combination of both.
In addition to evidenced-based treatment modalities,
psychodynamic psychotherapy is widely utilized and
integrated into the care plan of children and adoles-
cents when indicated. Although overall evidenced-
based treatment modalities have proven to be highly
effective in treating a range of psychopathology they
also have been confronted with some challenges.
Challenges mainly embody implementation and sus-
tainability in community mental health clinics. In order
to practice and deliver evidenced-based treatment to
children and adolescents, clinicians must be well
trained and highly skilled. One time initial trainings
have proven to be insufficient and ongoing clinical
case consultation is necessary.30 At times, recruitment
359
of licensed clinical professionals has been difficult for
community clinics and turnover has been high. The
greatest challenge has been to deliver these treatment
modalities to a diverse population of youth in a
culturally thoughtful, competent, and sensitive manner
as most of these treatment modalities were designed in
well-resourced academic settings with a low ethnic/
racial mix of patients and families.31 Agency-wide
adoption of the EBT and fidelity to the model requires
agency leadership and financial resources at a mini-
mum.32,33 This section will review several promising,
effective treatments that have been widely used in
children and adolescents of varying ethnic and racial
backgrounds and psychopathology. The following
evidence-based treatment modalities were selected
and described below because of their positive results
with at times our most complex and challenging
patients: children and adolescents who have suffered
from some form of abuse, endured or witnessed
significant trauma, in foster care, in the juvenile justice
system, and/or with co-occurring substance abuse.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) has been the
foundation for evidenced-based medicine. Due in part
to the productive interplay between research and
clinical practice, it is thought that cognitive behavioral
therapy is the psychotherapeutic treatment of choice
for youth with mood and anxiety disorders.34 Aaron
Beck developed cognitive behavior therapy as a treat-
ment intervention for depressed adults. Cognitive
therapy concentrates on identifying and correcting
cognitive distortions and progresses from focusing on
symptoms and behaviors to a focus on situation,
specific thoughts and finally to a focus of the central
core beliefs of the individual. Work begins linking
emotions, behavior, and thoughts. The goal of treat-
ment is to restructure the individual’s thoughts, chal-
lenge them, and practice positive counter thoughts to
negative statements.35 Over the past 2 decades, empir-
ically supported CBTs covering the range of childhood
onset depressive and anxiety disorders including post-
traumatic stress disorder (PTSD) have emerged includ-
ing trauma-focused CBT.
Integrated Co-Occurring Treatment Model
The Integrated Co-Occurring Treatment (ICT) model
for youth is an integrated treatment program that uses
360
treatment and service elements modified to the speci-
alized needs of youth with co-occurring mental health
and substance abuse disorders. It is currently utilized
by a number of evidenced-based practices (i.e., multi-
systemic therapy, multidimensional family therapy,
and functional family therapy). ICT uses a multi-
stage progression treatment approach (engagement,
persuasion, active treatment, and relapse prevention)
and utilizes motivational interviewing as a method to
facilitate readiness for change.36
Functional Family Therapy
Functional family therapy (FFT) is a brief family-
centered approach, often used for children and adolescents
aged 11–18 years at risk for and/or presenting with
delinquency, violence, substance use, conduct disorder,
oppositional defiant disorder, or disruptive behavior
disorders. In FFT, the family’s focus is shifted away from
the youth’s problem behavior and onto the patterns of
behavior between family members, with the aim of
establishing more positive familial interaction patterns.
FFT clinicians guide families through five stages (engage-
ment, motivation, relational assessment, behavior change,
and generalization) and incorporate other evidence-based
behavior change techniques, such as cognitive behavioral
therapy. FFT is commonly utilized by child-serving
systems such as juvenile justice and child welfare, to
prevent serious youth delinquency and out-of-home
placement.36,37
Multi-systemic Therapy
Multi-systemic therapy (MST) is one of the best
available treatment approaches for juvenile offenders
with mental health treatment needs. MST is an intensive,
multi-modal, family-based approach which has demon-
strated decreased rates of rearrests by 70% and out-of-
home placements by 64%, improvements in familial
functioning, and lower rates of mental health disorders in
serious juvenile offenders.36
Wraparound Approach
The wraparound approach is a form of intensive care
coordination for children and adolescents with signifi-
cant mental health conditions. Wraparound services link
the youth’s strengths and needs to services and supports
within his or her community. It is a team-based,
collaborative process for developing and implementing
Curr Probl Pediatr Adolesc Health Care, November 2016
individualized care plans for children and adolescents
with complex needs and their families.24 This service
delivery model focuses on all life domains and includes
clinical interventions and natural supports to keep the
child at home, in the community, in school and out of
trouble. Outcome evaluations revealed a 60% reduction
in the use of residential treatment and an 80% decrease
in psychiatric inpatient hospitalization.36
Multidimensional Treatment Foster Care
Multidimensional Treatment Foster Care (MTFC) is
a comprehensive, family-based behavioral intervention
for adolescents with severe and chronic emotional and
behavioral disorders in out-of-home care.38 Adoles-
cents are placed with trained, local, and supervised
families for approximately 6–9 months. Throughout
the MTFC placement, family therapy is also con-
ducted. It has been demonstrated that youth receiving
MTFC spent 60% fewer days incarcerated than those
not receiving services, and also had significantly fewer
arrests. For girls in particular, MTFC appears to have
even more benefits such as fewer criminal referrals,
less days in locked setting, lower self-reported delin-
quency, and decreased deviant peer affiliation. MTFC
also proved efficacious and impacted positively non-
targeted outcomes such as, lower pregnancy rates,
school attendance, and completion of homework and
an overall decrease in depressive symptoms.38
Crisis Intervention Teams
Mobile crisis services have been highly effective in
de-escalating acute, intense emotionally charged situa-
tions and mitigating out-of-home placements—in-
patient hospitalizations in particular.24 The crisis inter-
vention team is usually comprised of two mental health
professionals who attempt to engage the child and
family and resolve the crisis and/or determine need for
further assessment and stabilization in the emergency
room. Specialized law enforcement programs have been
designed as well in several states that provide crisis
services. Crisis intervention teams (CITs) were devel-
oped by communities to facilitate and encourage diver-
sion from the juvenile justice system and referral of
adolescents with mental disorders to appropriate serv-
ices. As an example, The Children in Crisis (CIC)
program in Denver, CO, was implemented by the police
department in 2010, for the goal to recognize mental
illness, and offer resources to provide follow-up care for
Curr Probl PediatrAdolesc Health Care, November 2016
youth in distress. Police first de-escalate the crisis and
then refer the youth for services. CIC training includes
information on trauma and adolescence, how to
approach traumatized youths, developmental milestones,
common mental illnesses among adolescents, response
tactics during calls, and the nature of psychiatric
emergencies.36
Parent–Child Interactive Therapy (PCIT)
PCIT is a highly specialized short term intervention
for disruptive behaviors in young children that incor-
porates principles of play therapy into structured
behavioral parent training. PCIT draws from social
learning and attachment theories to emphasize positive
attention, consistency, problem solving, and effective
communication. PCIT has been shown to decrease
behavior problems in young children, decrease parental
stress, and increase parental confidence. It is also
showing positive signs in reducing internalizing symp-
toms in young children as well.39
Parent Management Training (PMT)
Parent management training derives from behavioral
therapy which integrates the concepts of positive
reinforcement, negative reinforcement, punishment,
and/or extinction. PMT provides psychoeducation
and support to parents in implementing positive praise
and reinforcement, behavioral checklists, attending and
ignoring behaviors, effective communication and
parent stress management. PMT has demonstrated
enhancements in parent functioning and a decrease in
disruptive behaviors in the child.40
Collaborative Care Models
Integrative Behavioral Health
Children’s mental health problems are among the
leading causes of disability for children and adoles-
cents, and if left untreated, these significantly disrupt
healthy development, resulting in chronic disability
into adulthood. Indeed, half of all lifetime mental
illness begins by 14 years of age and three-quarters
by 24 years of age.41 More concerning is the average
delay (8–10 years) between onset of symptoms and
biopsychosocial intervention for children, which are
critical developmental years in the life of a child.42
Factors driving such severe delays include the shortage
of mental health workers, the stigma associated with
361
receiving mental health services, chronic underfunding
of the public mental health system, reduced reimburse-
ment to mental health providers, and disparate insur-
ance benefits.43 Because approximately 75% of all
children with psychiatric disabilities are seen in
primary care settings, and half of all pediatric office
visits involve behavioral, psychosocial, or educational
concerns,9,44,45 pediatricians act as de facto mental
health clinicians. The pediatric health home then
represents an opportunity to increase identification of
mental and behavioral health issues and provides
greater access to mental health services.
The American Academy of Pediatrics characterizes
care from a pediatric medical home as accessible,
continuous, comprehensive, collaborative, compas-
sionate, culturally competent, and family centered.46
To care for the whole child, in the context of family,
school, and community, the medical home needs to
have effective and dynamic relationships among com-
munity agencies and services that may assist the child
and family for a variety of needs. This philosophy
aligns with the collaborative approach within child-
ren’s mental health services and promotes models of
shared care between medical and psychiatric care
providers. Responding to this movement toward coor-
dinated care through the medical home, the American
Academy of Child and Adolescent Psychiatry has
outlined recommendations and best principles for
integrating child and adolescent psychiatry into the
pediatric health home.47 The principles include family-
focused care, professional collaboration, care plan
development, and care coordination.
In family-focused care, patients and families are
essential partners with health care providers, identify-
ing strengths and needs, developing comprehensive
treatment plans, implementing and evaluating mental
health services, and ensuring that services are cultur-
ally appropriate. Professional collaboration entails
child and adolescent psychiatrists serving as consul-
tants to pediatricians through both direct and indirect
service activities. Direct service collaboration involves
joint direct treatment of affected children, with child
and adolescent psychiatrists providing consultation or
evaluation, biopsychosocial formulation, diagnostic
impressions, and treatment/referral recommendations.
Indirect service collaboration includes bidirectional
access to medical records, provision of education and
skill building in primary care providers to assess and
treat mental health problems, and support for such
undertaking. Care plan development and care
362
coordination are essential for several reasons: the
mental health system is complicated and difficult for
families to navigate, mental health systems are often
administered and reimbursed through different mech-
anism than medical services, communication between
specialty mental health providers and pediatricians
requires structural assistance to improve, and for
children with complex psychiatric needs, care coordi-
nation ensures that all involved parties coordinate their
individual efforts for the benefit of the child. Most
importantly, however, is the fact that children and
adolescents develop and function in different domains
and systems, requiring a coordinated comprehensive
approach to any care they receive.
The mental health care components within the
pediatric health home include prevention and screen-
ing, early intervention, routine assessment and treat-
ment, specialty consultation, specialized treatment,
coordination of services, and monitoring. To meet
these responsibilities, a tiered framework of service is
recommended, based on the severity, chronicity, and
complexity of mental health problems for individual
patients.13 As each of these criteria intensifies, the
responsibility of the primary care provider for treat-
ment and planning decreases while that of the child
psychiatry specialty system increases. The levels range
from preventive service and screening, with more
responsibility on the PCP, to early intervention and
routine care provision, to specialty consultation, treat-
ment, and coordination, and ultimately to intensive
mental health services for complex clinical problems.
At every level, however, both pediatric and psychiatric
providers are involved and provide input, from sup-
portive to primary treatment roles to facilitating/direct-
ing more intensive services, all existing in a fluid
construct based on the needs of the child. What
develops is a cohesive team approach to holistic care
of a child and his/her family.
Integrated care models require collaboration on many
fronts, not just between individual physicians. Collab-
oration across staff levels and disciplines, involvement
of families, and a willingness to rethink processes are
necessary elements of integrating psychosocial con-
cerns with the more medical model of primary care.48
Mental health services seem to exist in a system apart
from the general health care system, even when they
occur in the same organization. This situation is
represented and reinforced by separate “carved out”
insurance and payment systems, separate medical
records systems and practices, and separate state
Curr Probl Pediatr Adolesc Health Care, November 2016
regulatory systems. Reimbursement for the substantial
indirect time and effort required to bridge the divide
between these two sectors is poor or nonexistent.49
Current fee-for-service financing models do not reim-
burse non-face to face consultations or care coordina-
tion that promote family-focused collaborative care,
and the health home is not expected or incentivized to
develop coordinated linkages with community part-
ners. Sustainable funding strategies need to be devel-
oped for integrating psychiatry into the pediatric health
home.50
Pediatricians are in a unique position to serve a vital
role in prevention, early detection, initial management,
and coordination of care for childhood mental illness.
They regularly educate caregivers about normal behav-
ior and development and counsel parents regarding
child-rearing and behavioral management. Relationships
and rapport built over years of well-child visits and
continuity of care allow pediatricians to inquire about
sensitive issues, destigmatize them, and offer guidance
and treatment. Collaborative care models maximize
providers knowledge and abilities, facilitate alliances
with families, and work to overcome constraints within
and beyond health care systems, all with the goal of
providing access to high-quality mental health care to
children and adolescents and their families.51
Mental Health Screening
One of the hallmarks of pediatric practice is preven-
tion, as evidenced by routine screenings of multiple
health indices throughout the growth and development
of children, including growth charts, vision, hearing,
lead levels, and urinalyses, among others. Prevention of
mortality and morbidity secondary to many conditions
depends on effective screening and referral procedures
in pediatric primary care.52 The extent of screening
procedures for treatable yet relatively uncommon con-
ditions such as metabolic disorders, indicate the value of
such screenings. Therefore, screening for more preva-
lent illnesses, the impact value multiplies. Estimates
reported by the Surgeon General indicate that one in five
children has a diagnosable mental illness53; 9–13% of
US children and adolescents aged 9–17 years meet the
definition of “serious emotional disturbance” and more
than half of these experience “extreme functional
impairment.”54 Even greater numbers have behavioral
or emotional problems causing impairment or distress
that do not meet criteria of the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition. Moreover,
Curr Probl PediatrAdolesc Health Care, November 2016
developmental and behavioral health disorders are now
the top five chronic pediatric conditions causing func-
tional impairment.55
Reflective of the growing understanding of the
impact of mental health on children, the push for
mental health screening arises from multiple domains
within society, including medicine, government, and
industry. The American Academy of Pediatrics Task
Force on Mental Health56,57 provides guidelines for
pediatric primary care; the United States Preventive
Services Task Force58 outlines recommendations for
depression screening in youth; Early Periodic Screen-
ing, Diagnosis, and Testing (EPSDT) of Medicaid
patients requires mental health assessment of all
covered children59; the Patient Protection and Afford-
able Care Act of 2010 mandates that commercial health
plans offer depression screening60; and the Surgeon
General’s interdepartmental collaboration underscored
the need for pediatric mental health screening.61
The rationale for pediatricians performing mental
health screening aligns with the nature of primary
pediatric practice. First, children generally seek health
care and make decisions through a proxy, usually a
parent. Second, children undergo rapid developmental
changes and screening recommendations change with
each well-child visit.62 Third, for many families,
especially those with young children, pediatric care
providers serve as gatekeepers to mental health and
developmental services.63 Fourth, in evaluating and
promoting optimal health and well-being, the domains
of development and behavior must be considered
together within the context of the family, a perspective
in which pediatricians are uniquely positioned.
As relationships and rapport are established between
families and pediatric providers, pediatricians become
privy to sensitive information that can profoundly
impact the growth and development of their identified
patients. The Adverse Childhood Experience Study64
revealed that adverse early experiences were related to
increased rates of health problems in adulthood,
including substance abuse, mental health problems,
and poor health-related quality of life, and the effect
was bidirectional. Later, data from the 2003 National
Survey of Children’s Health demonstrated a strong
linear relationship between increasing number of
psychosocial risk factors and many poor health out-
comes, including social–emotional health. Such was
the impact that the American Academy of Pediatrics
issued a policy statement advocating for viewing the
causes and consequences of toxic stress from the same
363
perspective as other biologically based health
impairments.65
Yet to date, mental health screening within pedia-
trics, while improving, remains far from universal and
further follow-up after positive screens are woefully
limited. The reasons are numerous and complex.
Repeated periodic surveys of pediatricians reveal
several barriers to mental health screening, ranging
from provider issues to patient issues to systems issues.
Identified barriers included lack of training in treatment
of children with mental health problems, lack of
confidence, presumed patient refusal, lack of time,
lack of office support, inadequate reimbursement, and
inadequate referral resources.66 Moreover, pediatric
practices that do attempt to implement mental health
screening encounter difficulties with the process itself,
including engagement of youth and their families in
screening and how clinicians evaluate initial screening
results and use them to make clinical decisions.67
Wissow and colleagues performed an extensive sys-
tematic review revealing the impact of these two
issues, finding that factors contributing to these ele-
ments of implementation directly affected success of
the screening projects. VanCleave et al.68 found that
successful primary care screening programs incorpo-
rated a multifaceted approach to implementation,
involving alterations in office workflow, physician
staff education, collaborative learning, tailoring to
best fit the specific practice, and ongoing outcome
assessment.
The AAP in its 2015 clinical report Promoting
Optimal Development: Screening for Behavioral and
Emotional Problems, integrated the current under-
standing of children’s mental health with its place
within pediatric practice and provided guidance to
pediatric clinicians for implementation.69 Six different
steps are outlined to give pediatricians a clear roadmap
to implementing behavioral and emotional screening in
practice: (1) readying the practice, (2) identifying
resources, (3) establishing office routines for screening,
(4) tracking referrals, (5) seeking payment, and (6)
fostering collaboration. In addition, multiple areas
within the US have formed collaboratives, seeking to
educate, train, and assist pediatricians in implementing
mental health screening in their practices. Two such
programs are the DC Collaborative for Mental Health
in Pediatric Primary Care and the Ohio AAP Building
Mental Wellness Learning Collaborative. Screening
and educational tools, support, and guidance for
ongoing assessment are provided and meeting with
364
success (unpublished data). As pediatricians are often
the first point of entry into mental health systems,
screening in primary care for mental health issues is
paramount, allowing for timely identification, early
intervention, and possibly secondary prevention of
multilevel impairment in children and adolescents.
School Mental Health
Mental health in children, adolescents, and youth is
at a point of crisis. It is estimated that one in five
children within the United States of America has a
diagnosable mental illness; however, less than one
third are actually receiving services or treatment.70 In
the wake of unsettling suicide rates, bullying, homi-
cides, youth violence, and trafficking, the Nation’s key
stakeholders are taking critical steps to combat barriers
that have stagnated progress. Access to care remains a
huge challenge largely due to limited workforce, poor
geographical distribution of providers, the lack of
cultural and linguistically sensitive services, lower
socioeconomic status, and financial burden. As a
result, children with mental health concerns remain
unidentified or are wrongly funneled into juvenile
systems with more punitive consequences than reha-
bilitative care. Youth of lower socioeconomic status,
living in poverty, face an increased risk yet are chief
among those experiencing difficulty accessing consis-
tent and reliable care. As a result, children’s mental
health issues become adult mental health issues with
greater financial impact and reduction of productivity.
It is therefore paramount that health care professionals
meet children and their families where they are in order
to increase connectivity and to improve mental health
service delivery among our youth. School based
mental health services afford the opportunity to do
just that with the delivery of care in an atmosphere of
familiarity and trust.
The Need For Schools
With nearly 50 million school age children enrolled
in the public school system alone, schools are a logical
entry point for the delivery of mental health serv-
ices.71,72 By law, children are required to attend school
(public, private, or homeschool) for a period of time
making it a key place for mental health promotion,
early identification, intervention, and treatment. In
their policy statement on School Based Mental Health
Services, the American Academy of Pediatrics stood in
Curr Probl Pediatr Adolesc Health Care, November 2016
full support stating, “school-based programs offer the
promise of improving access to diagnosis of and
treatment for mental health problems of children and
adolescents. Pediatric health care professionals, educa-
tors, and mental health specialists should work in
collaboration to develop and implement effective
school-based mental health services.”73 It is clear that
schools cannot do this work alone, and need to draw
upon support from community partners to be most
effective.
The Role of Collaborative Relationships and
Engagement in Schools
Collaborative partnerships are essential to providing
a full continuum of care, a central goal of mental health
services. These relationships enable school districts to
expand mental health services within schools, thereby
increasing access, reducing cost, and maximizing
resources. But access alone does not guarantee uti-
lization. Students must be properly engaged and
educated regarding the need for such services and the
role the school plays in its delivery.74 Lindsey et al
found that assessment, accessibility, promotion, psy-
choeducation, homework, and assessing barriers to
care proved effective in engaging youth and their
families. These practices were associated with partic-
ular outcomes of interest – attendance, cognition, and
adherence.75 From that work, evidenced-based profes-
sional development workshops were created as a
means to equip providers with the needed techniques
to engage students and their families.76 Engagement
should therefore be a top priority when coordinating
the delivery of services within schools.
School Based Mental Health Service Delivery
Models
The notion of delivering mental health services in
schools raises the hard questions - what are schools
realistically equipped to do and how can they do it
optimally? Traditionally, mental health needs have
been met by school psychologists, counselors, and
social workers; however, given the increased number
of unmet needs within schools, ways to supplement
this work are greatly needed. Collaborative care
models afford schools the ability to expand needed
mental health services and to provide an array of
services in the way of promotion, prevention, inter-
vention, and in some cases treatment.
Curr Probl PediatrAdolesc Health Care, November 2016
Promotion
Mental health promotion focuses on well-being and
healthy development. It bears an offensive approach
that empowers and supports individuals who are not
identified as “at risk.” It is thus provided to everyone
via universal application. In the context of school
mental health, promotion targets the “whole child” and
offers a range of care that addresses the social-emo-
tional, cognitive, and cultural facets of the child. The
emphasis is on creating a positive milieu that envelops
youth and surrounds them with value-driven experi-
ences that build their sense of self within their schools,
homes, and communities.77
Prevention
Mental health prevention is a system of care designed
to improve the identification of and support for “at
risk” individuals with learning and/or behavioral con-
cerns. Interventions are stratified across 3 tiers and vary
according to the level of perceived severity, and
need.78

Primary Prevention: Universal supports made
available to all children within the general student
body. Services are delivered by social workers,
psychologists, and mental health specialists as
part of school-wide and classroom initiatives.
Primary prevention is intended to assist students
in the development of a positive sense of self and
well-being so as to mitigate negative psychosocial
factors that commonly precipitate serious mental
illness. Examples include anti-bullying cam-
paigns, school rules/expectations, and skills train-
ing.78 The Positive Behavioral Intervention and
Supports (PBIS) program is an example of a
National preventive initiative. This evidence-
based approach aims to enhance academic and
behavioral outcomes for all students by focusing
on social behavior.79

Secondary Prevention: Supports made available
to “at risk” students, identified as those who
would likely benefit from early intervention
services. Secondary prevention represents a more
targeted approach to the delivery of services for
those requiring an elevated level of care. Services
are often provided in group settings and focus on
coping strategies for youth and skills training for
those persons working them. Examples include
365
 conflict resolution programs, peer mentoring, and
check in/out services.78

Tertiary Prevention: Supports made available to
students with chronic needs who failed to respond
to lower levels of intervention, requiring a more
intensive and individualized approach. Examples
include individualized counseling, individualized
behavior plans, and wrap-around services.80
Treatment
Mental health treatments come in a large variety of
services. Modalities range from in- school counseling
services provided by school-employed staff, in-school
psychiatric consultations/management provided by
community psychiatrists, to fully integrated on-site
health clinics with services provided by community
medical and mental health providers. School Based
Health Clinics (SBHC) represent the intersection of
health and education. As of 2014, there were 2,315
SBHCs serving students and communities in 49 of 50
states and the District of Columbia.81 Services are
provided on site, during school hours, during desig-
nated breaks and delivered by licensed professionals.
There are several notable benefits to SBHCs including
increased access to care, reduced stigma, and the
increased sense of ownership in their health care.82
One study assessing the use of mental health services
across delivery sites found adolescents 21 times more
likely to come to mental health visits at school based
health clinics than community health center net-
works.83 SBHCs provide comprehensive healthcare;
however, in the absence of a best-practice model
challenges remain.
Protection for Students with Disabilities:
Special Education and Section 504
Under The Individuals with Disabilities Education
Act (IDEA), children with disabilities (regardless of
type) are entitled to a free and appropriate education
(FAPE).84 As stated this includes, “Any child between
ages 3-21 years who has been evaluated under
Individuals with Disabilities Education Act standards
who is mentally retarded, speech-or-hearing impaired,
deaf, a victim of traumatic brain injury, visually
impaired, orthopedically impaired, autistic, learning-
disabled, possesses another health impairment qualifies
for special education if the pre-existing impairment
affects the learning potential of the child.”84 As a
366
result, an individual education plan (IEP) must be
created for every child qualifying for special education.
The supportive services are largely overseen by an
IEP team consisting of the child, the child’s
parents, a general education teacher, a special educa-
tion teacher, a school psychologist, and an advocate
(if applicable).
For students with disabilities not qualifying for
special education services but still necessitating the
need for addition support, Section 504 of the Rehabil-
itation Act of 1973 protects them against discrimina-
tion of service.85 By putting a “504” in place, these
children are eligible to receive appropriate classroom
modifications. For example, a child with Attention
Deficit Hyperactivity Disorder may benefit from
accommodations such as movement breaks, preferen-
tial seating, and other classroom supports provided by
the 504 plan.
The Lack of Standardized Service Delivery
Models in Schools – A Missing Link
In general there is no universal mechanism for
coordinating the delivery of services across the educa-
tional, mental health, and primary health care systems.
The lack of a cohesive model functioning as the
standard of care, leaves many opportunities for frag-
mentation of services.86 Though it is not ideal for the
federal government to enforce a standard, it should at
minimum provide specific core features that all school
based mental health programs should have. These
guidelines should reach well beyond broad recommen-
dations and give details around the quantitative and not
just the qualitative make-up of the collaborative team.
Current models of care define the roles of school and
community employed personnel but less often specify
a quantitative mandate for their services. For example,
state school counseling mandates and legislation dras-
tically vary state to state with a fair share of states
lacking counseling mandates for elementary and sec-
ondary schools. The average mandated school counse-
lor-to-student ratio is 1:500.87 Not uncommonly, states
have a provision such that elementary and secondary
schools with fewer than 500 students only need one
half-time school employed counselor.88 This is of great
concern given the substantial unmet mental health
needs of the nation’s youth. Consequently this places
an undue burden on school staff thus causing an
internal barrier to care.
Curr Probl Pediatr Adolesc Health Care, November 2016
Challenges
Despite the growing support for mental health
services in schools, school districts continue to encoun-
ter challenges such as limited workforce, fragmenta-
tion of services, increased school enrollment,
undocumented minors, program sustainability, and
funding.85 States’ ability to shoulder finances varies
throughout the country. School based health centers
rely on a braided model of financial support including
patient revenue, public and private-sector grants, and
partner contributions.89 Regarding fiscal sustainability,
though few SBHCs have closed over the years they are
operating in less than 2.5% of all K-12 public
schools.71,81,90 Additionally, of those SBHCs operat-
ing, approximately 25 % do not offer mental health
services on-site.90 Aside from financial factors, sus-
tainability is also hindered by ill-equipped program
leaders, initiative overload, and lack of evidence based
practices to guide effective implementation.78 In mov-
ing forward, a leading practice model should seek to
address all pertinent barriers while providing clear
roles and expectations of key stakeholders involved.
Next Steps: A Case for the Involvement of
Consulting Firms in School-Based Mental
Health Collaborative Models
Although the inception of school based mental health
programs is far beyond its infancy, it has yet to reach
full maturity. A new horizon is dawning for healthcare,
rich with opportunities to transform the industry and to
further develop its mechanisms for service delivery.
The time is nigh for re-strategizing and focusing on the
strengths and the skillsets needed for a successful team.
Traditionally, key stakeholders have included the likes
of educators, mental health professionals, policy mak-
ers, program directors, and other medical care special-
ists; however, given the brokenness of the current
delivery system, perhaps more oversight is needed to
navigate an increasingly complex healthcare land-
scape. There exists an advisory role for consulting
firms in school-based collaborative care models. Typ-
ically, these entities have been called upon to assist
health systems with developing operating models that
address the realities of financial challenges, service
delivery inefficiencies, and limited evidence-based
practices. In an ideal circumstance, such a consultancy
would prove effective in helping school-based pro-
grams develop and execute a leading practice model
Curr Probl PediatrAdolesc Health Care, November 2016
that meets these challenges and achieves sustained
service delivery in dynamic health care environments.
Summary
Strong evidence exists for the need of mental health
services in schools. Fragmentation of services has led
to multiple and often duplicative initiatives. School
based mental health is a viable and promising option
for the delivery of high-quality healthcare to children
and adolescents who may otherwise go unidentified.
Largely, school based mental health services answer
the question regarding access. In the absence of
sustainable guiding principles, programs are at risk of
premature failure. Collaborative models are critical to
the strategizing, planning and implementation efforts
needed to improve effective delivery of mental health
services for children and adolescents nationwide.
Culturally Informed Care
Culturally competent health care is essential not only in
the United States but also across the globe. In the past 2
decades, there has been tremendous growth in ethnic
minority populations coupled with the clear need for
service delivery systems of care for a diverse population
of children, adolescents and their families. Although
there have been major efforts to promote culturally
competent services, the Surgeon General’s report on
Mental Health: Culture, Race and Ethnicity91 demon-
strates that equality in access, quality and outcomes for
the minority youth and adults has not yet been achieved.
For example, African American youth were more likely
to be diagnosed significantly more with conduct disorder
and psychosis, than with mood and anxiety disorders.
African American youth were also and more frequently
involuntary hospitalized than their Caucasian peers on
adolescent in-patient units despite same level of aggres-
sive and self-injurious behaviors during treatment.92
Although African American and Latino youths are
identified and referred from primary care at similar rate
as youths in general populations, they are less likely to
receive specialized mental health services or psycho-
tropic medications.93 This is concerning given that Latino
and Asian American girls have the highest rates of
depression.94
In addition to health care disparities in quality of
mental health care for racial and ethnic minority groups
in the United States, there are many other barriers that
367
minority youth and families confront when attempting
to access mental health care. These barriers include
fragmentation of services, lack of availability, cost, and
stigma. These barriers actually exist for all children and
adolescents but may have a more profound impact on
ethnic minority youth. When important elements such
as mistrust and fear of treatment, different cultural
perspectives and belief systems on mental health and
illness and linguistic variances are considered, these
barriers have a staggering effect on health seeking
behaviors in ethnic minority youth and their families.95
Decreasing mental health care disparities and barriers
to treatment and quality care requires the collaborative
involvement of federal, state, and local agencies. It is
also extremely important to include stakeholders in the
community to identify and remove barriers to enhance
quality and access to mental health care for all children
and adolescents and for ethnic minority children in
particular. It is important to note, however, that once
the child and family present to a provider’s office for
evaluation and treatment, all the collaborative work of all
agencies and stakeholders will be futile if a family is
confronted with a provider who is not culturally sensitive
and competent. If the child and family feel unheard,
misunderstood, disrespected or even discriminated
against, the child will most likely be lost to follow-up
treatment and care. Given that untreated mental illness
can lead to school dropout, substance use, juvenile
detention, and even more tragic outcomes—suicide,
providing culturally sensitive and competent care can
actually change life trajectories.96
In an effort to promote higher cultural competency in
mental health care providers, the Diagnostic and Stat-
istical Manual of Mental Disorders (5th ed.; DSM-5;
American Psychiatric Association, 2013) has outlined a
cultural formulation, which provides a framework for
assessing information about cultural features of patient’s
mental illness in the context of social and cultural
differences. DSM-V defines culture as “systems of
knowledge, concepts, rules and practices that are learned
and transmitted across generations. It includes language,
religion, and spirituality, family structures, life-cycle
stages, ceremonial rituals, and customs as well as moral
and legal system” (American Psychiatric Association).
In promoting competency, an ability to navigate within
the context of cultural beliefs and behaviors, providers
are able to engage with the patients in an efficient
manner and improve treatment outcomes.
The first category that the cultural formulation
emphasizes is the cultural identity of the individual;
368
during an assessment, one’s racial, ethnic, or cultural
reference group that influences one’s identity should be
noted by the provider. The cultural identity is not only
limited to one’s origin, but it includes one’s language
fluency, socioeconomic background, and degree of
social integration especially for immigrants in partic-
ular. Acquiring better understanding of a child or
adolescent’s cultural identity is essential for the pro-
vider to comprehend the patient’s illness from the
patient’s perspective. This is extremely important in
pediatric ethnic minority patient populations as most
navigate both their parent’s cultural ecosystem and
their own generational one. Culturally diverse children
develop their own cultural identity by retaining some
of their original cultural identity and also adopting the
mainstream culture. In the process, they learn flexi-
bility to perform in multiple cultural contexts and
openness to different cultural perspectives. However,
inability to develop these characteristics could lead to
identity diffusion, or negative identity formulation.98 It
is also important to assess the cultural identity of the
parents as their language and communications are
critical in obtaining accurate clinical information and
establishing a therapeutic alliance. Use of interpreters
with proper training in both the skill of translation and
content is paramount to accurately elicit and under-
stand clinical signs and symptoms, history of present
illness and complete patient history in order to
comprehensively assess the child or adolescent and
establish a therapeutic alliance. Using siblings or the
child as interpreter or language broker has been found
to be ineffective and counterproductive in the context
of the therapeutic process.
In providing culturally informed mental health care,
paying close attention to cultural conceptualization of
distress is also significant in order to provide the
appropriate standard of care. Cultural and family context
of symptomology needs to be considered as typical and
atypical clinical presentations are discerned and identi-
fied for treatment purposes. Ethnic minority families
may understand the complexity of their child’s symp-
toms in the context of their own culture, idioms, and
perceived cause. It is crucial for providers to examine
cross-cultural dynamics such as inter-generational con-
flicts regarding acculturation, or marginalization from
one’s own or mainstream culture when formulating their
patient’s clinical presentation. In working with ethnic
minority youth, clinicians should also assess the coping
style of the family, and their help seeking behaviors. For
example, it is not uncommon for Asian Americans to
Curr Probl Pediatr Adolesc Health Care, November 2016
delay and seek mental health treatment until symptoms
are quite severe due to shame not only for the child,
adolescent or young adult, but also for the family. It is
also likely that they might have sought out other non-
traditional medicinal healers prior to reaching the
physician’s office such as alternative medicine, cultural,
or even spiritual leaders.
Treatment of minority children should also incorpo-
rate psychosocial stressors as well as cultural features
of vulnerability and resilience. Behavioral problems of
the child could be the product of his/her family
dynamics, as well as social situation. It is important
to identify not only the key stressors, but also the key
supports within the family’s social environment and to
draw strengths from the social structures such as
friends, neighborhood, and community resources. In
that process, consultation and intervention by tradi-
tional healers from diverse cultures can be a powerful
component of culturally competent care.98 Consulting
with or referring to ethnic minority practitioners in the
process of treatment of the patients could also be an
effective strategy and a way to draw strength from the
cultural community.99
One of the most integral parts of cultural competency
is recognition of cultural features of the relationship
between the child’s family and the clinician. It is noted
that delay or refusal to seek needed care usually arises
from mistrust, perceived discrimination, and negative
experiences in interaction with the health care sys-
tem.100 A trustful relationship with the provider can
only be achieved with a value-neutral approach, and
being open to various cultural influences on the child
and the family.101 An effective communication with
the patient could result in lower rates of early dropouts
and missed appointments for psychiatric treatment,
which are a persistent problem. Providing comprehen-
sive psychoeducation for both medication management
and therapy is crucial in engaging ethnic minority
families. In navigating a foreign system of mental
health care, culturally diverse families need more in
depth and careful attention from the provider. Collab-
oration with a traditional cultural family decision
maker who might be outside of the nuclear family,
and empowering the family by education about med-
ication is important in reducing the mistrust and
perceived discrimination of the family, and promoting
rapport with the provider.
According to the Four Racial and Ethnic Panels,
culturally informed mental health care for minority and
culturally diverse populations should start from the
Curr Probl PediatrAdolesc Health Care, November 2016
community settings since this is where they feel the
most comfortable; they are able to assess the services
in familiar and natural settings (i.e., schools, religious
institutions, and medical homes) which are non-
threatening.102 In order to provide better mental health
care to ethnic minority youth and families, there should
be a strategic plan to address health care disparities
which would necessitate national and state wide
collaboration. It would also be important set standards
for culturally competent and informed behavioral
health services, and systematic changes promoting
cultural competency and sensitivity for institutions,
providers and staff.
Youth in Foster Care
The number of children in foster care in the United
States is over 500,000 and continues to rise. This is a
special population of children who have been mal-
treated and subsequently removed from their families
of origin and displaced in a new home, new neighbor-
hood, new school, with new people with the burden of
loss, separation, and trauma on their shoulders. This
special population of youth is disproportionately Afri-
can American and Latino. In addition to the initial
insult of removal and displacement, they may have or
continue to live in poverty with poor resources,
suboptimal educational opportunities, and ongoing
exposure to urban community violence. Providing
and accessing quality mental health care for foster
children may appear to be the least of the challenges
that these youth confront each day, however, it is a
service that is greatly needed by this marginalized
group of children that continues to be inadequate and
flawed.
Studies have shown that children in foster care are
more likely to be diagnosed with a mental illness, more
likely to be hospitalized for a mental illness, and have
greater mental health expenditures than other children in
the child welfare system.103 It has also been shown that
foster care children are more likely to have chronic
physical disabilities, birth defects, developmental delays
and poor school achievement as compared to children of
the same socioeconomic background.104 Once a child
receives services, it has been shown that they are more
likely to experience discontinuity of care which impacts
their overall quality of health care.105
As a child is moved from foster home to foster home
their health care is fragmented. With multiple different
providers, the medical and mental health history is at
369
times not communicated or lost with the transition.
Thru the years, recommendations have been made to
improve the access and quality of services for this
population such as creating a database where informa-
tion is housed and shared by health care providers and
foster care agencies, or utilizing “medical passports”
which documents important medical history that the
foster parent brings to each appointment.104,105
National efforts have been made to improve the
quality of care for foster children such as creating
incentive programs for governmental agencies over-
seeing the care of these children, collaboration of
academic medical centers and child welfare agencies
and monitoring psychotropic medication utilization in
these children. However, violence continues in our
communities and schools. Sound futures of success,
health and well-being for this special population of
youth, are still tenuous and questionable. Thus, despite
the aforementioned gains, so much more works need to
be done to promote healthy outcomes for these
children. Once a child comes into treatment it is
important that the designated clinician has the clinical
skills to effectively assess and treat the child and their
family. Practitioners that come into contact with foster
children have a vast array of clinical experience and
expertise ranging from bachelor’s degrees to medical
degrees. It is essential that these clinicians are equipped
with the appropriate clinical skills to treat this pop-
ulation of youth.
Although children and adolescents in foster care have
been shown to be a population of youth that are most in
need of comprehensive mental health services, access
and quality of services continues to be flawed. Fur-
thermore, once the child receives services the appro-
priateness and efficacy are at best marginal with
treatment outcomes being overlooked and challenging
to measure. Often children whom have been abused or
neglected have complex clinical presentations and
even practitioners with sound clinical acumen can find
these children difficult to treat (Saunders, 2003).
Practitioners are often searching for guidelines on
best-practice methods to care for this “hard-to-treat”
population.
Evidenced-based treatment modalities are widely
viewed as best practice models for psychotherapeutic
treatment for children and adults. Promising studies
have shown that CBT is an effective psychotherapeutic
treatment for maltreated and sexually abused
children and adolescents.35,106 Trauma-focused CBT
in particular has been successful in treating children
370
and adolescents in the child welfare system
(Saunders, 2003).
Youth in Juvenile Justice System
Similar to children and adolescents in foster care,
youth in the juvenile justice system often have experi-
enced traumatic events, multiagency involvement with
complex clinical presentations. Addressing the mental
health needs of children and adolescents in the juvenile
justice system requires a collaborative approach.
Poverty and maltreatment appear to play a critical
role in offending trajectories of children and adoles-
cents.107 Among girls, trauma, sexual abuse, family
conflict, and mental health concerns are related to
juvenile or adult arrests. Among boys, community and
peer-related conflicts may be more influential. Family
characteristics, such as low parental education, parental
mental illness, maternal substance use, discipline
practices, and parental stress have been associated with
adolescent substance abuse, conduct disorder, and
criminality.107
Since 1997, juvenile incarceration rates have
declined by 42%. The United States, however, still
has the highest rate of juvenile incarceration among
industrialized nations.108 Girls appear to make up a
growing percentage of the juvenile justice population.
From 1985 to 2009, delinquent crimes among girls
increased by 86%. For boys, however, rates of
delinquency increased only slightly by 17% over that
same time period. Unlike boys entering the legal
system, girls are most often nonviolent offenders
who present with numerous psychosocial challenges
including elevated rates of child abuse (up to 84% of
justice-involved girls reporting some kind of trauma
exposure), violence exposure, mental health problems,
family conflict, pregnancy, and school failure.109
Moreover, substantial racial disparities in juvenile
justice involvement continue to persist. The rate of
violent crime arrests in 2005 for African American
juveniles was more than five times the rate for White
youth.110
Justice-involved youth are at a great disadvantage—
they have suffered and endured the perils of numerous
psychosocial, familial, and environmental stressors
while battling their own mental illness. Approximately,
50–70% of the 2 million youth who encounter the
juvenile justice system meet criteria for a mental
disorder.36 It is estimated that approximately 15–30%
of justice-involved youth have diagnoses of depression
Curr Probl Pediatr Adolesc Health Care, November 2016
or dysthymia, 13–30% have diagnoses of attention-
deficit/hyperactivity disorder, 3–7% have diagnoses of
bipolar disorder and 11–32% have diagnoses of post-
traumatic stress disorder.36 And despite the high
prevalence of mental disorders in pretrial detention
centers, only 25–30% actually receive treatment while
in detention.36 The most startling fact is that these signs
and symptoms emerged prior to and possibly led to
their detainment but most children and adolescents
tend to end up in the juvenile justice system first and
never become involved or appropriately engaged in
mental health services.111
The most effective treatment models that have
demonstrated delinquency-reducing benefits for chil-
dren and adolescents with mental disorders include
functional family therapy, multidimensional treatment
foster care, and multi-systemic therapy. Interestingly,
all of these therapeutic models are similar in that they
involve families and youth, are community-based, and
deal with problem behaviors and stressors as a
systemic family unit. Essentially these treatment mod-
els represent an integrated system of care. These
evidenced-based treatment modalities have remarkably
reduced recidivism rates of justice involved youth with
mental disorders.36
The juvenile justice system was originally designed
to be rehabilitative. But in the end, where do these
children and adolescents stand? It appears that once a
youth becomes involved in the juvenile justice system,
there is a higher likelihood that he/she will remain
tethered to the criminal justice system into adulthood
with the potential negative sequelae of adult incarcer-
ation, substance use and economic hardship.108
For youth who do come to the attention of the
juvenile court, it is imperative that the system is
prepared to meet the needs of chronically traumatized
youth with significant mental health problems, cogni-
tive impairments, and academic difficulties. Policies
that support a trauma-informed juvenile justice system
should emphasize trauma screening and assessment,
evidence-based trauma treatment, cross-system
engagement, literacy skills and academic enrichment,
and promote resilience and engagement among youth
and families.112 Strengthening academic skills, partic-
ularly in language skills, may improve health outcomes
and also reduce delinquency and recidivism rates.113
With intervention, there is great potential of positive
trajectories of children and adolescent in the juvenile
justice system. Positive or “promotive” factors to
consider when working with children and adolescents
Curr Probl PediatrAdolesc Health Care, November 2016
are positive peer relationships, family involvement,
low parental stress, and good housing quality are all
prosocial behaviors that have been related to refraining
from delinquency.110
LGBT Youth
Lesbian Gay Bisexual Transgender (LGBT) individ-
uals represent a group of individuals whose sexual
orientation may differ from heterosexual attraction, and/
or may include individuals whose gender identity differs
from the gender they were assigned to at birth. Sexual
orientation can be further broken down into multiple
components of how one self-identifies their sexual
orientation, their sexual behavior, and to whom they
are sexually attracted. All three of these components
may not align as one would expect. For example, some
youth may identify in the clinic as being straight (or
heterosexual), yet may be experiencing attraction to
individuals of the same sex. This factor makes research
and understanding of the prevalence of sexual minority
youth difficult as many adolescents are still developing
and how they choose to identify may evolve over time.
Previous studies in the literature showed prevalence
rates in school samples of approximately 3% of students
in grades 9–12 identifying as gay, lesbian, or bisex-
ual.114,115 Terminology that is used in the LGBT
communities to describe sexual orientation and gender
identity has grown to help encompass the infinite array
of identities in these communities, and these factors can
make it difficult to accurately estimate the prevalence of
LGBT youth. Although it may seem an impossible task
for a provider to keep up with different definitions and
terms, providers should not make assumptions and
should always ask the patient how they would like to
be identified to help increase comfort of youth in the
provider’s office. Although one could also find defini-
tions of terms from various sources, there is variance in
how terms are defined and how a given individual may
interpret and use the terminology. Therefore, clinicians
should also use caution in not making too many
assumptions on how their patient uses a term or take a
given definition as the only acceptable use. Some of the
more common terms that have been used outside of
“lesbian,” “gay,” “bisexual,” and “transgender”; include
concepts of “asexuality” for individuals that do not feel
they have an interest in sex or sexual attraction,
“pansexuality” for individuals that are attracted to
individuals of all gender identities, “agender” for those
that do not identify with a particular gender identity,
371
“gender fluid” for individuals that may have gender
expressions or identities that vary with time, “gender
queer” or “non-binary” to identify individuals that do
not identify in the binary gender system of being either
male or female.
Over recent years, there has been much media
attention and increased activism toward improving
rights for LGBT individuals. One does not have to
look far to find LGBT youth in television, movies and
books; providing more role models for LGBT youth.
There has also been increased positive acceptance in
the United States toward LGBT individuals and
providing LGBT rights, such as same-sex marriage
and preventing discrimination.116,117 This has also
coincided with recent trends that in LGBT individuals
coming out and disclosing their identities at younger
ages in adolescence.118 As a result, there is a need for
mental health providers in the community to be
sensitive and attuned to the unique challenges and
mental health disparities in the LGBT communities.
Recent studies have emerged looking at some of the
mental health disparities that LGBT individuals face,
making this a unique population that deserves special
consideration when providing mental health care in the
community.
It is very important to dispel the idea that one’s
sexual orientation or gender identity in of itself is
pathological. The psychiatric community made efforts
to depathologize homosexuality after it was removed
from the DSM in 1973. Similarly in 2013, in the
publication of DSM-5, “Gender Identity Disorder” was
removed and the condition of Gender Dysphoria is
listed to put the emphasis that one’s gender identity is
not disorder or pathological, but the distress that some
individuals experience can be addressed and treated.97
It is important to note that although there are numerous
studies that have been emerging showing disparate
rates of conditions such as depression, anxiety, suici-
dality, and substance use; it is not due to one’s sexual
orientation or gender identity, but the undue stress that
these minority groups face compared to the general
population. Meyer applied one of the prevailing
theories related to this idea using the Minority Stress
model for LGBT individuals, hypothesizing that the
stigma, prejudice, and discrimination that LGBT
individuals may face creates a stressful social environ-
ment that leads to mental illness.119
In terms of mental health disparities that impact
LGBT Youth, more research has emerged recently
looking at the differences and unique challenges that
372
some of these youth face. Suicidality is a concern for
all adolescents regardless of their sexual orientation or
gender identity, given that suicide is the second leading
cause of death for both the 10–14-year-old and
15–24-year-old age groups according to the CDC.120
When looking at sexual minority youth (lesbian, gay,
or bisexual), multiple studies have shown that these
youth are more likely to attempt suicide when com-
pared to their heterosexual peers. A recent meta-
analysis of 19 studies that looked at rates of depression
and/or suicidality in sexual minority and heterosexual
youth, showed that on average 28% of sexual minority
youth reported a history of suicidality versus 12% of
heterosexual youth. When looking at the severity of the
suicidality, the disparities increased as the intensity
worsened going from ideation, to having a suicide plan
or intent, to actually attempting, and having an attempt
that required medical attention.121 When looking at
intent, another study showed that 58% of Lesbian Gay
Bisexual (LGB) youth that attempted endorsed “really
wanting to die” versus only 33% of heterosexual youth
endorsing the same statement.122 Similar to sexual
minority youth, transgender youth also show signifi-
cant rates of suicidality, which is not surprising given
the similar negative factors of facing harassment from
peers, negative parent reactions, and violence. Gross-
man and D’Augelli showed in a sample of transgender
youth that were interviewed, 45% had seriously
thought of suicide and 26% had history of a suicide
attempt.123 In another study using a community sample
of self-identified transgender patients matched to
cisgender controls, there was significant elevations in
rates of suicidal ideation (31.1% versus 11.1%), rates
of suicide attempts (17.2% versus 6.1%) and history of
self-injury (16.7% versus 4.4%).124 In a community
sample of 246 LGBT identified youth, Mustanski et al.,
showed that approximately 1/3 of the sample met
criteria for a mental disorder, 15% for major depression
and 9% for PTSD.125
Numerous studies have examined disparities between
substance use in sexual minority youth (lesbian, gay,
bisexual identified youth). Marshal, et al. performed a
meta-analysis of 18 studies looking at rates of substance
use in sexual minority youth and found overall odds of
substance use to be 190% greater than compared to
heterosexual youth. Other significant trends included
much higher odds of substance use in bisexual identified
youth and stronger risks when looking at specific drugs
such as injection drugs and cocaine compared to heavy
alcohol use or marijuana use.126 Less is known about
Curr Probl Pediatr Adolesc Health Care, November 2016
differences in substance use in transgender youth,
however in a survey study of high schoolers in New
Zealand, transgender identified youth were 2.9 times as
likely to report that they drank alcohol on a weekly
basis.127
Another critical factor for LGBT youth is the impact
and role that schools can have on both helping provide
positive support, but also being a source of additional
stress due to harassment or bullying in the school
environment. Studies have shown that sexual minority
youth typically have more excused and unexcused
absences from school. When asked, sexual minority
youth also report higher levels of depression and
anxiety.128 Other studies have also shown that a sense
of a lack of safety contributes to some of the school
absenteeism rates in sexual minority youth, as only one
in seven lesbian or bisexual identified females or one in
five gay or bisexual males report feeling a high degree
of safety in school.129 Although less research has
looked at transgender youth’s experiences, the GLSEN
National School Climate Survey in 2010–2011 showed
that out of 705 self-identified transgender students,
75% had endorsed regular verbal harassment, 32%
endorsed regular physical harassment, and 17%
endorsed regularly being physically assaulted.130
On the other hand, schools have also been a shown to
be a critical environment for intervention. Goodenow
showed that LGB adolescents that were in schools that
had Gay–Straight Alliances (GSA) which is a support
group for LGBT youth in the school setting were less
likely to report being victimized and less likely to
report suicide attempts compared to schools without
GSAs.131 Further, LGB youth that were in schools
with HIV instruction that they saw as being sensitive to
LGB health concerns were less likely to use alcohol or
drugs prior to sexual activity, less likely to have had
sex in the last 3 months, and had fewer sexual
partners.132 Transgender youth that were in schools
that had GSAs, LGBT inclusive curriculums and
perceived educators to be supportive were less likely
to report being bullied.133 Given the relationship
between the increased stress LGBT youth face in the
school environment and the implications this stress has
on effecting mental health disparities, mental health
providers should look to schools as potential places of
advocacy and intervention for their patients.
Another area for provides to consider in supporting
LGBT youth is working with family systems. Ryan et al.
showed through their Family Acceptance Project through
interviews with LGB adolescents a number of behaviors
Curr Probl PediatrAdolesc Health Care, November 2016
that families use to show both acceptance and rejection.
They then showed that LGB young adults that identify
higher levels of rejecting behaviors in their families had
much higher rates of concerning symptoms and behav-
iors, such as having 8.4 more likely to having attempted
suicide, 5.9 as likely to report high levels of depression,
3.4 more likely to report illegal drug use, and 3.4
more likely to report having unprotected sexual inter-
course.134 However, of critical importance is that pro-
viders protect confidentiality of their patients and do not
prematurely disclose a child’s sexual orientation or
gender identity. In those cases, where parents are aware
of their child’s sexual orientation or gender identity and
with the youth’s permission, clinicians could provide an
important role in promoting accepting and supportive
parenting behaviors as well as provide psychoeducation
to promote well-being, such as the fact that one’s gender
identity or sexual orientation is not pathological or
something that can or should be changed. It is clear that
given the current trends of more LGBT individuals
disclosing their sexual orientation and gender identity at
younger ages, those that provide care to all youth need to
be well informed and comfortable working with
LGBT youth.
Unaccompanied Minors Arriving From Central
America
By the year 2050, it is projected that Hispanics will
be 32% of the total population of the United States of
America135 (USA). Central American Youth are the
fastest growing ethnic minority group in the USA. The
majority of the children and youth from Central
America are coming from the countries of Honduras,
El Salvador, and Guatemala. These countries have
faced political and civil struggles, civil war, genocides,
coupe d’etat since the early 1980s leading to displace-
ments and forced migrations. Today, this area, origi-
nally known as the Northern Triangle for commercial
purposes, has become known worldwide as the most
violent region in the world. Being alive and young is
the greatest risk factor for being a victim of violence as
half the people killed are adolescents. Homicide rates,
which serve as an indicator for violence levels, rose
above 50 deaths per 100,00 habitants in 2014.136
The United Nations High Commissioner of Human
Rights claims that acts of violence and abuse character-
ize the daily life of many children in these countries
and has identified the movement of unaccompanied
and separated children (UASC) displaced by violence
373
as a growing concern.137 These multiple levels of
violence created a dramatic increase in the number of
both family units and unaccompanied children arriving
in the USA as a phenomenon commonly known as “the
surge.” From a humanitarian perspective the situation
for these unaccompanied minors and others is unique
as this forced displacement is fueled by violence and
civil unrest and not secondary to the acute impact of a
natural disaster or conflict.138 Given the particular
political conditions, these unaccompanied minors
migrating to the United States become what are known
as hidden populations.139 Hidden populations are those
groups within societies for whom there is lack of
empirical data due to limitation in sampling frames and
privacy concerns and in this particular case because
membership involves illegal status.140 In general,
knowledge about the health status of immigrants is
limited due to lack of data141 and limited systematic
research focusing on the long-term psychological well-
being of immigrant children.142 Although no specific
profile is provided for deported unaccompanied minors
from the USA, the demographic profile of deported
minors from Mexico reveals an increase in two
especially vulnerable groups over the study period:
children younger than 12 and adolescent girls.143
Migration and Health
Migration is a global phenomenon influencing the
health of individuals and populations.144 There are
several aspects of health to be taken into consideration
in the migration process of these unaccompanied minors
that can influence their mental health outcomes. Children
are dependent on adults for protection, care, and
decision-making. By migrating unaccompanied, they
TABLE. Some aspects of the various migration stages that can affect migrant health145
Pre-departure146
Biological and genetic factors
Infectious and chronic disease epidemiological profile
Social factors (education, housing, and poverty); behavioral effects on
health including nutrition and diet; access to and use of care;
management of existing illness, violence and risk-taking behaviors
Environmental Factors(geographic, weather, political)
Migrant status: refugee, irregular migrant
Culture/experiential factors: differential in health service utilization
and expectations
374
lack safe attachment figures, lack of protection in the
journey, and lack of parental guidance in the accultur-
ation process which can increase their vulnerabilities
(Table).
Pre-departure Conditions
Local conditions and environment at the place of origin
influences a child’s health during all phases of the
migration process. These pre-departure health character-
istics are important drivers in the overall mental health
and well-being of unaccompanied children.147
The following case study illustrates the journey of unaccompanied
children across the stages of migration: pre-departure
Johanna is a 14-year-old female from El Salvador, who departed her
home country on July 4, with the hopes for a better education, reunite
with her mother and support her family financially. Her mother asked
her to leave, as she feared for her safety. Her father was recently shot
to death by a local gang. They were living in conditions of extreme
poverty and dreadful violence. Mother reported her to be a healthy
child.
According to a recent report,148 children are migrat-
ing from Central America to the USA fleeing from
violence—violence from organized crime, commun-
ities controlled by youth gangs, and domestic violence.
There is also economic despair, lack of opportunities
and hopes of reunification with family members,
especially their parents, who had fled their country
leaving them behind. The Committee of the Rights of
the Child is concerned, in particular, at the level of
violence present in the home, which remains very high
and continues to rise, in spite of numerous initiatives
taken by the State to prevent domestic violence.149
It is extremely important to comprehend the perva-
sive victimatization that these children and adolescents
Transit Destination
Travel conditions and mode Migration-related and health
(lack of basic health policies
necessities)
Duration of journey Legal status and access to services
Traumatic events, abuse Inclusion or discrimination
and violence
Alone or mass movement Language and cultural values
Separation from family
Duration of stay
Appropriateness of health services
Abuse, sexual violence,
exploitation, working, and living
conditions
Curr Probl Pediatr Adolesc Health Care, November 2016
experience at multiple levels in their life experience
and unaccompanied journey into the US. These youth
have most likely been subjected to torture or sexual
violence, poor and inadequate somatic and mental
health care including substance abuse, and must
navigate both linquistic and cultural contexts on their
own.150
The travel and destination
Johanna arrived the last week of September. She was traveling
unaccompanied with smugglers and was captured by a gang named
“Los Z.” She was held captive for a total of 8 weeks in an abandoned
school in Mexico until her mother paid $3100 for her release. During
this captivity, she was only fed one meal a day, was sexually
assaulted, and witnessed gruesome violence. She was detained in the
Southern Border and little is known about this experience. After
3 weeks she was reunited with her mother and her mother’s new
family. Adaptation was difficult for Johanna. She struggled with the
language in particular.
During their journey, unaccompanied minors usually
come by themselves or with a Coyote (smugglers) or as
part of a group. Their travel can be perilous, which may
lack basic health necessities and high exposure to multi-
ple traumatic events as illustrated by the above case.
Because of misinformation about US immigration
policies most likely being communicated by smug-
glers, many unaccompanied alien children (UAC)
actively seek out US authorities, believing that the
US grants temporary immigration status which has
contributed to the spike in numbers and this behavior at
the borders.151 Once the accompanied youth cross the
border they are apprehended. Several agencies in
the Department of Homeland Security (DHS) and the
Department of Health and Human Services’ (HHS)
share responsibilities for the processing, treatment, and
placement of UAC.152 Once apprehended and charged
with violating the United States immigration laws,
unaccompanied alien children (UAC)—“those younger
than 18 without lawful immigration status who have no
parent or legal guardian in the country available to
provide care and custody”—enter a disjointed system
which they must navigate alone and without legal
representation.153
UAC are usually placed in detention centers near
international borders that function as field prisons,
often with inadequate health care. Medicine Sans
Frontiers in Mexico in 2012 provided 5800 medical
consultations and 10% were for physical violence,
10,000 psychological consultations in which 42% were
related to violence. Overall, 80% of migrant patients in
Curr Probl PediatrAdolesc Health Care, November 2016
Mexico reported witnessing violence.154 Detention
poses great risks to the health, well-being, and the
development of unaccompanied children. Challenges
to their mental health and well-being include cultural
and language barriers, poverty, low education levels,
substandard housing, lack of knowledge regarding
immunizations, lack of access to health care, lack of
access to quality early education programs, family
separation, discrimination, and constant fears of depor-
tation.155 Although mental health screening is a
mandated procedure at ORR shelters, questions around
the quality and nature of the process have been
raised.156
Issues to Consider
Mental Health and Psychopathology. Fazel et al.157
performed a systematic search and review of individual,
family, community, and societal risk and protective
factors for mental health in children and adolescents
who were forcibly displaced to high-income countries.
Among the individual factors, exposure to pre-migration
and post-migration violence, exposure to traumatic
event, and being a female were significantly associated
with an increased likelihood of psychological
disturbance in refugee youth. Among the family risk
factors, having either tortured or missing parents, and
awareness of parent detention are strongly associated
with poor mental health outcome and is an independent
predictor of post-traumatic stress disorder (PTSD),
respectively. Having a single parent in the household,
poor financial support, and parental psychiatric
problems were other familiar risk factors identified.157
Studies in accompanied minors performed in
Australia and United Kingdom have shown high levels
of psychopathology among asylum-seeking parents
and children. Preschool-aged children have been iden-
tified as exhibiting sleep and feeding disturbances and
significant developmental delays. Children between the
age of 6 and 17 years met clinical criteria for PTSD,
had somatic symptoms, anxiety, and rarely exhibited
self-injurious behavior.158 These difficulties seem to
arise as a consequence of the detention experience in
children. If they are apprehended in family units the
caring adults become vulnerable and parenting abilities
undermined. In the long term, there seems to be an
increased level of psychological distress, losses, and
disruptions in their social support networks and educa-
tional experiences. Gaps in the access to specialist
comprehensive mental and physical health assessments
as well as treatment provisions for children and
375
families in these detention centers have been identi-
fied.159 In the United States, Human Health Services
(HHS) is responsible for coordinating and implement-
ing the care and placement of UAC in appropriate
custody.152
Huemer et al.147 completed the first review exclu-
sively examining the mental health of unaccompanied
refugee minors. They found that compared to the
accompanied minors or non-refugees in general, unac-
companied minors showed a higher number of stressful
life events which were subsequently strong predictors
of internalizing behaviors and traumatic stress reac-
tions, resulting in elevated posttraumatic stress disor-
der symptoms. These youth demonstrated statistically
significant higher levels of exposure to physical and
sexual violence with girls subjected to sexual abuse at
greater rates than boys. Studies also highlighted higher
levels of depression and psychosis in unaccompanied
minors as compared to accompanied minors. These
unaccompanied refugee minors also experienced a
chronic course of traumatic stress with no improve-
ment in anxiety and depression symptoms in follow-up
studies. A follow-up study of unaccompanied minors
arriving at Norway before the age of 15 years were
reassessed 2 years into settlement for change in number
of stressful life events, symptoms of PTSD and
symptoms of depression, anxiety, and internalizing
problems. Although no average change in the level of
measures from 6 months into their arrival to the 2 years
postarrival were observed, a significant increase in
suicidal ideation was discovered. The authors con-
cluded that these trends indicate a chronic course of
stress reaction.160
A study focusing on a heterogeneous group of adult
refugee mental health patients with pre-flight experi-
ences of war and human rights violations receiving
specialist treatment in Norway, found a high frequency
of childhood adverse and potentially traumatic experi-
ences among its participants. There was a significant
association with increased mental health symptoms
and reduced quality of life in those adults with child-
hood experiences of extra- and intra-familiar vio-
lence.161 Thus, having a system in place for
unaccompanied minors that provides early interven-
tion, can potentially foster resilience. It should also be
taken it into consideration when planning interventions
for family units as the trauma can be inter-generational.
From and epidemiological perspective, a study in
Sweden compared inpatient psychiatric care of unac-
companied refugee minors (URM) and non URM and
376
they found that URMs were markedly overrepresented
in inpatient psychiatric care with increased self-harm
or suicidal behavior.162
Access to Health Care. Children and adolescents in
the United States, in general, have poor quality and
access to mental health services. Barriers to quality
health care include organizational, structural, and
clinical factors.163 To no surprise, migrants in
particular, face many challenges when attempting to
access health care.
Despite millions of children affected by forced
migration, there is limited research in potential school
and community interventions to support the mental
health and well-being of this population of youth.164
Notwithstanding the limited data, resources and the
stigma around mental health, studies in unaccompa-
nied refugee population can serve as a primer.
Pediatricians play a vital role in detecting, assessing
and proposing treatment for this vulnerable group of
children and adolescents.165 Below are recommenda-
tions to consider regarding Mental Health Assessment
and Mental Health Service Provision for UAC from
Central America:
(1) The System of Care values should be applied
when providing care for UAC arriving from
Central America: comprehensive community-
based services that are culturally and linguisti-
cally competent,166 youth guided and family
driven with evidence practice or practice-based
evidence. Translators trained in mental health
and/or language and cultural brokers should
always be used with this population, given the
care provider is not professional fluent in
Spanish. Although the component of family
driven might be initially be challenging due to
the very fact that these children and adolescents
are arriving in this country alone and without
intact family units, all efforts should be made in
order for this to be accomplished. Strong family
networks and community factors are potential
sources of support for UAC arriving from
Central America. A strong alliance and trust
must be built with the parents or caregivers first
as without it, this can easily become a barrier for
the youth to be involved in services.167
(2) There is a need to systematically improve the
understanding of these youth and their family
experience. Emphasis should be placed in
Curr Probl Pediatr Adolesc Health Care, November 2016
 developing a safe space of trust and security in
which children and adolescents can begin to
develop and fortify their sense of self.
(3) A strengths-based approach integrating the
youth’s resilience168 should be considered when
providing mental health services to UAC arriv-
ing from Central American. Resilience is fos-
tered and protective factors flourish when good
parental mental health (particularly in mothers),
high parental support, family cohesion, positive
school experiences, and same ethnic-origin fos-
ter care (when applicable) exists.157
(4) Because details of their past medical history may
be scarce, when working with patients who are
recent immigrants a good social history is the
cornerstone of the assessment. It should include,
the level of education, level of education of the
parents, number of generations in the United
States, number of years in the United States,
fluency in English, extent of support and com-
munity resources, change in social status due to
immigration, stress due to immigration and
acculturation, extent of personal relationships
with people from diverse cultural backgrounds,
and if reunified with parent after the unaccompa-
nied journey the immigration status of parents.
(5) The changing social networks and support
structures pertaining to the process of separation
and reunification with their family of origin in
the States should be explored with humility and
avoiding judgments or misinterpretation of the
complexity of these separations.142 Adaptation
to their reunified family construct is very diffi-
cult for most unaccompanied youth. A perceived
sense of isolation, difficulty following parental
rules, suicidal ideation and high-risk behaviors
has been observed. The acculturation gap is an
important factor to consider in the context of
these reunifications.
(6) Acculturative stress should be taken into con-
sideration when assessing the mental health of
UAC from Central America. Acculturation is the
process whereby elements of another cultural
group are learned, adopted and integrated into
an individual’s original culture. Acculturative
stress refers to the level of psychosocial strain
experienced by immigrants in response to the
immigration related challenges that they
encounter as they adapt to the life in a new
country. Although the studies are not specific for
Curr Probl PediatrAdolesc Health Care, November 2016
UAC, acculturative stress has a positive associ-
ation with suicidal ideation among Latino youth
and the risk of attempted suicide doubles.
Negative language brokering feelings can be
related to depressive symptoms and indirectly
related to increase alcohol and marijuana use.
(7) Thorough, comprehensive medical and mental
health assessments are the gold standard in
screening for somatic symptoms and elements
of distress that can be associated with depression,
anxiety, posttraumatic stress disorder, substance
abuse, and disruptive behavior disorders.
(8) Once comprehensive medical and mental health
assessments are completed and if indicated a
treatment plan is devised the most important
aspect of the care is that it is culturally competent
and informed at all levels and stages of treatment.
The treatment and service delivery model must
meet the child and family where they are. Natural
supports are essential and must be mobilized in
the community (i.e., appropriate school place-
ment, linguistic support and education, pediatric
medical home, social services regarding housing,
employment, vocational skills, etc.).
Unaccompanied minors from Central America have
different cultural backgrounds and although there are
similar exposures to violence, they might exhibit
different patterns of psychological distress. Thus, this
heterogeneity needs careful attention in terms of
clinical needs assessment and interventions. Allowing
the child or adolescent to tell their story is the first step
to building trust and a therapeutic rapport. In a medical
system in which evaluations are marked by time
constraints, it is extremely important that providers
do not fall prey to these pressures and carve out the
appropriate time for this therapeutic process to ensue.
Without their unfiltered story, the provider is left with
both limited knowledge and ability to engage this child
or adolescent and may miss important information that
can discern signs and symptoms to formulate an
accurate diagnosis and treatment plan.
The Immigrant Health Toolkit is a highly valued
resource developed by the American Academy of
Pediatrics. Section 5 of this Toolkit is on Mental,
Emotional and Behavioral Care169 which underscores
the importance of advocacy.170 Advocacy for unac-
companied minors should include priorities such as
reunification of children and adolescents with family or
other care providers, immediate and appropriate
377
educational placement and community-building activ-
ities and resources. A critical function for the primary
team in collaboration with community and social
services is that of educating mainstream providers
about immigrants0 traditional cultural practices and
idioms of distress. It is also important to educate and
assist immigrants from diverse cultures in understand-
ing different cultural norms and practices in their new
environment (i.e., Corporal punishment).171
Beyond health care provision, working with unac-
companied minors is an opportunity to make this
vulnerable population visible and to advocate for the
rights of children and for them to realize their
significance and power as political agents172 in society.
With these efforts, we can attempt to ensure the
development of healthy minds and bodies and positive
life trajectories.
The Role of Training and Education
Even with new innovations and integrated models of
care, there still must be highly skilled child mental
health professionals trained and available to provide
these much needed services. Efforts to address the
significant workforce shortage of child and adolescent
psychiatrists across the globe must strengthen. Capti-
vating young minds even prior to medical school, to
learn about and understand mental illness is a wonder-
ful way to ignite a person’s interest in pursuing the
field of child and adolescent psychiatry. The NYU
Child and Adolescent Mental Health Studies (CAMS)
Program exemplifies this type of effort and has thus far
had a very positive influence on these college students’
lives. The CAMS Program currently has over 40
courses, an annual enrollment of approximately 3000
students and is designed to provide an integrated area
of study for undergraduate college students that targets
an increase in knowledge of mental health issues in
children, adolescents, and emerging adults; encourages
mental health service utilization on college campuses;
and exposes young minds to the possibilities of work-
ing with children and adolescents in the mental
health field.
Student evaluations of the courses have overall been
affirmative, and reported that their participation in the
program had a positive impact on their life (84.2%) and
impacted their career choice (60.2%).173 This type of
collaboration between a College/University and an
Academic Department of Psychiatry seems to be a
378
“win–win” and may ultimately both decrease stigma
and enhance understanding of mental illness and lead
more young passionate minds into the field of child
psychiatry.
Once the interest in the field of child and adolescent
psychiatry is piqued and students have entered medical
school or have even begun an adult psychiatry
residency program, eligibility for loan repayment
programs can be extremely helpful in securing a future
in practicing as a subspecialist and also possibly in
underserved areas. The need for well-trained highly
skilled child psychiatrists practicing in underserved
areas is tremendous. As a requirement of the Accred-
itation Council of Graduate Medical Education
(ACGME), while in training, both didactic and clinical
experiences in child and adolescent fellowship pro-
grams should enhance the residents0 knowledge base in
systems of care, cross-cultural psychiatry and com-
munity mental health so that they are well equipped
and desire to work in the field.
Community-Based Mental Health
Services—A Global Perspective
Community-based mental health programs engage
multiple partners and stakeholders, build upon existing
infrastructure, and ultimately aim to provide services
that are acceptable and relevant to the community as
well as cost-effective and sustainable. Until relatively
recently, in high-income and low- and middle-income
countries alike, mental health services have been
concentrated in tertiary care centers and institutions
rather than integrated into community settings. Over-
centralization of mental health services limited the
degree of family and community involvement and
reinforced stigmatization of psychiatric illness. Poor
oversight and inadequate conditions in institutions
often led to the abrogation of human rights of
individuals afflicted with mental health disorders.
Many communities have had difficulties accessing
mental health treatment due to high cost, a dearth of
trained providers, and inadequate and unevenly dis-
tributed resources. In the last few decades, there has
been a worldwide movement to transition toward
community-based mental health models to address
these concerns.174
The growing recognition of the impact of psychiatric
illness on economic and public health indices has
fueled this movement. Mental health and neurological
Curr Probl Pediatr Adolesc Health Care, November 2016
disorders, particularly depression and alcohol use
disorder, are leading causes of disability and lost
productivity.175 Moreover, psychiatric disorders fre-
quently co-occur with other chronic diseases; integrat-
ing mental health interventions into community-based
primary care centers may improve overall health out-
comes.176 War, displacement, poverty, and natural
disasters cause psychological distress and increase
susceptibility to a number of psychiatric conditions.177
Indeed, catastrophic events around the globe have
underscored the dire need for mental health systems
to care for communities in distress.
These events have also exposed vulnerabilities in
existing systems, including the scarcity of pediatric
mental health services in most areas. Mental health
systems and diagnostic schema have not typically
addressed the singular needs of children. Existing
estimates of prevalence and measures of disability
are adult-centric and so the full scope of the pediatric
problem is unknown. However, available data suggest
that a high proportion of children (12–29%) around the
world experience mental health problems.178 Funda-
mental child rights—access to basic needs, security,
education, play, consistent and emotionally available
caregivers—underpin a healthy developmental trajec-
tory. Children whose circumstances jeopardize their
ability to access these rights are at higher risk for
developing psychological distress and psychiatric ill-
ness. Pediatric mental health disorders may be detected
first in child-serving institutions such as schools, social
services agencies, and juvenile justice systems, yet
mental health interventions are not always readily
available in those settings.
This article will identify critical barriers frequently
encountered in community-based mental health treat-
ment in diverse global settings; discuss initiatives that
address these challenges; and review lessons learned in
the implementation of mental health programming in
the context of disasters, with a particular emphasis on
the needs of children.
Global Challenges in Community-Based
Mental Health
Identification and diagnosis of mental health disor-
ders is challenging in a global context. The vast
majority of relevant research has been conducted in
high-income countries. There is debate about how well
the biomedical psychiatric diagnostic scheme, which is
predominant in high-income countries such as the
Curr Probl PediatrAdolesc Health Care, November 2016
United States and the United Kingdom, can be
generalized across multiple, diverse cultural milieus.
Although many screening and diagnostic tools have
been translated and validated for cross-cultural use,
these instruments may not capture culturally specific
idioms and concepts of distress.179 Especially given a
history of health interventions that have exploited
subpopulations with less political power, including
persons with psychiatric illness, intellectual disabil-
ities, and developmental disorders, mental health
interventions must be designed and undertaken with
a focus on human rights and cultural competence.
In addition to the complexity of psychiatric diagnosis
in persons presenting for assessment and treatment,
another barrier to providing community-based mental
health interventions is stigma. Stigma can limit the
number of individuals who actually present for treat-
ment and has been linked to a number of negative
outcomes. Self-stigma—one’s own feelings of self-
loathing and worthlessness—can work in concert with
more external sources of stigma. Evidence of stigma-
tization of psychiatric disorders may take the form of
overtly hostile attitudes and treatment (e.g., assault,
bullying, involuntary institutionalization) and discrim-
ination (e.g., limited access to housing, education,
employment, or health care). Stigma may be encoded
into language and idiomatic expressions, commonly
the use of pejorative terms to describe individuals with
mental illness and the use of psychiatric diagnostic
terms as epithets. In a variety of cultural contexts, in
high and low/middle-income countries, psychiatric
symptoms are attributed to flaws in character, morality,
or religious devotion. Persons with mental health
conditions may be avoided or denied full inclusion in
the community. Stigma can lead to a lack of acknowl-
edgment or even concealment by family members;
negative attitudes and treatment may also be general-
ized to family members who may themselves face
discrimination and social and economic obstacles as a
result. Institutionalized stigma entails underapprecia-
tion of the scale or importance of mental health needs,
inadequate resource allocation, lack of investment in
infrastructure, and separation of mental health treat-
ment from general medical health systems and private
insurance policies. Stigma has been linked to decreased
help seeking, treatment discontinuation, poor self-
esteem, and disruption in interpersonal (including
family relationships).180 Stigma and fear may contrib-
ute to health care practices that isolate patients with
psychiatric illness from the community; notably, 25%
379
of persons admitted to psychiatric facilities worldwide
remain institutionalized for more than 1 year.175
Despite increasing global mental health awareness,
there continues to be significant resource and infra-
structure limitations. It is estimated that 75% of
individuals in low income countries who have mental
health disorders are without treatment.181 Only 60% of
countries have a dedicated mental health policy. The
average amount spent per person, per year on mental
health services is roughly US $2 overall, with an
average closer to US $0.25 in low-income countries.
Mental health spending accounts for less than 2% of
overall health budgets. Two-thirds of mental health
funding is directed toward psychiatric hospitals and
most psychiatric institutions are concentrated in urban
areas, leaving rural areas under-resourced.175,182 Even
when there are available systems of care, services may
still be inaccessible due to cost. Out of pocket expendi-
tures are the most common form of payment for mental
health services in low income countries. In countries
where social insurance is available, benefits may accrue
based on employment and earnings histories. Individu-
als with chronic mental health disorders are more likely
to have experienced unemployment and low earnings
and may be eligible for fewer benefits. Private health
insurance programs that are available in high-income
countries may exclude and significantly limit coverage
of mental health services. Privately insured patients
often still have considerable out-of-pocket expenses for
services not funded by insurance.183
The worldwide shortage of mental health professio-
nals is another barrier to increasing access to services.
The persons who can most effectively deliver services
and step into mental health delivery roles may vary by
cultural context and community, but the mental health
workforce consists primarily of psychiatrists, psychol-
ogists, nurses, ad social workers. Globally, nurses are
the professionals who comprise the largest proportion
of the mental health workforce. Psychiatrists are much
more available in high-income countries compared
with low income countries; high-income countries
have 172 times more psychiatrists.184 Half of the
world’s population lives in an area with one psychia-
trist per 200,000 people (WHO mhGAP). There is an
estimated shortfall of 11,000 psychiatrists, 128,000
nurses, and 100,000 other psychosocial professionals
in low and middle-income countries.185 Highly trained
professionals in middle and low income countries
frequently migrate to high-income countries where
employment opportunities and income-earning
380
potential are greater, exacerbating the shortage of
providers in low and middle-income countries.
Task shifting—the training of non-specialists to
provide mental health care—has been employed to
address the shortage of mental health workers. Non-
specialist health professionals, family members, and
peers assume responsibility for aspects of mental
health treatment in order to increase the capacity of
the system to meet the mental health needs of the
community. Task shifting may also provide a mecha-
nism for incorporating mental health interventions in
community settings such as homes, schools, social
services agencies, and prisons. Task shifting has been
utilized for initiatives as varied as identifying persons
who are at risk for psychiatric illness, delivering
cognitive behavioral therapy, and providing psychoso-
cial support. Positive outcomes for task shifting pro-
grams have included improved functioning in persons
with psychiatric disability, improvement in measures
of maternal depression, and reduction of caregiver
burden. Psychosocial interventions administered by
non-specialists in primary care may be helpful and
cost-effective in adult populations. However, the data
on effectiveness of task shifting programs is mixed
and pediatric data is very limited. Primary care
providers are also frequently overburdened, making
the provision of mental health services challenging.
Moreover, an adequate supply of specialists is still
needed to provide training, ongoing supervision, and
management of complex cases.184,186,187
Global Pediatric Mental Health Initiatives
Although there are significant challenges in funding,
staffing, and implementing community mental health
interventions, there are ongoing coordinated efforts
between governments, non-governmental agencies,
and academic institutions to overcome these obstacles.
In addition, there is a burgeoning literature about
possible cost-effective interventions.
The World Health Organization Mental Health Gap
Action Programme (mhGAP) was founded in 2002;
its objective is to provide resources to guide evidence-
based treatment and scaling up of services, partic-
ularly in under-resourced settings. It focuses on
common neurological and psychiatric disorders
including depression, schizophrenia and psychosis,
epilepsy, dementia, alcohol and other substance use
disorders, and pediatric mental health disorders. The
strongest pediatric mental health recommendations
Curr Probl Pediatr Adolesc Health Care, November 2016
from the program thus far are in support of inter-
ventions that promote mother and infant interaction,
treat maternal depression, and provide home visiting
and psychoeducation for mothers with depression.
mhGAP advises against use of psychopharmacologic
treatment of children by non-specialists for depres-
sion and disruptive behavior disorders (WHO
mhGAP).
Though historically infectious diseases were a pri-
mary target of global health efforts, the 2010 Global
Burden of Disease Study underscored the fact that the
leading causes of mortality and morbidity worldwide
are non-communicable illnesses. A significant propor-
tion of disability adjusted life years (DALYs) are
attributable to psychiatric, neurologic, and substance
use disorders. These disorders also impact adherence
and treatment outcomes for other chronic communi-
cable and non-communicable diseases. As a response
to this data, the National Institutes of Mental Health
(US), the McLaughlin-Rotman Center for Global
Health (CA), and the London School of Hygiene and
Tropical Medicine convened the Grand Challenges in
Mental Health initiative in 2011. It is an effort that
seeks to identify global mental health research prior-
ities and to provide guidance for scaling up of mental
health initiatives. More than 400 stakeholders repre-
senting 60 countries have participated. The effort calls
for system-wide approaches to care, evidence-based
interventions, use of a life-course and developmental
approach, and an understanding of environmental
influences. The group has identified 40 grand chal-
lenges, many of which relate to the care of pediatric
patients. For example, the group has advocated for the
integration of mental health interventions into primary
care settings and schools, more training of professio-
nals who can provide evidence-based interventions to
children, promotion of parent support programs, and
creation of national child mental health policies. In
addition, the group has called for development of
interventions that explore the impact of childhood poverty
on mental health outcomes,188 www.nimh.nih.gov/about/
organization/gmh/grandchallenges/index.shtml).
Pediatric primary care interventions that may be
helpful and relevant to mental health include preven-
tion of malnutrition, lead poisoning, and infectious
causes of developmental disabilities as well as family
planning. A combination of nutritional, parenting, and
educational interventions improve psychosocial out-
comes. Life skills training may reduce substance
abuse, adolescent pregnancy, and improve academic
Curr Probl PediatrAdolesc Health Care, November 2016
performance. Though the evidence base is limited and
more controlled studies of programs are needed, there
are initiatives that have demonstrated benefit on child
mental health outcomes. In Kingston, Jamaica, for
example, 129 children who were living in poverty and
exhibited evidence of failure to thrive were included in
a home visiting program. They received nutritional
supplementation as well as home visits by community
support workers who were trained to facilitate play and
stimulation by parent. At 17-year follow-up, there were
lower rates of depression, anxiety, attention problems,
and school suspensions in the intervention group.
Zippy’s friends, a school-based program, is another
intervention for children that has shown promising
results. The curriculum centers on coping and inter-
personal skills and explores themes such as friendship,
empathy, and conflict resolution. It has been imple-
mented in multiple high, middle, and low income
countries. Children who participate in the program in
kindergarten may have an easier transition into primary
school and teachers who are trained in the method feel
more confident in their abilities to listen to their
students (Patel, 2008).
Lessons Learned From Disaster Response
Catastrophic events such as war and natural disasters
typically prompt an emergency response that includes
some element of psychological support for affected
persons. As many as one-third of individuals who
experience a traumatic event will develop PTSD; other
psychiatric disorders such as Major Depressive Disorder
and Substance Use Disorders are highly correlated with
trauma as well. Individuals who do not meet criteria for
a psychiatric diagnosis still experience psychological
distress and may need support. While traumatic events
increase the risk of new-onset psychiatric disorders, the
disaster response should not presume a lack of pre-
existing conditions; in fact, persons with prior diagnoses
of psychiatric illness often experience worsening symp-
toms in the context of disaster and require targeted
interventions. In the acute phase following disasters, the
goals of mental health responders are to conduct a
mental health needs assessment, reduce distress and
provide comfort, normalize emotional reactions, provide
community-based interventions, make referrals to the
appropriate level of services, and offer evidence-based
treatment and follow-up for those in need. More
research is needed regarding which mental health
interventions are most helpful following a traumatic
381
event. While there is little evidence to support the
effectiveness of psychological debriefing, there is gen-
eral consensus that psychological first aid should be
provided. Goals of psychological first aid include
attending to bodily safety and basic needs, cultivating
an environment of compassion, providing opportuni-
ties for individuals to articulate concerns, providing
relevant information and resources, facilitating connec-
tion to family and social networks, assisting with
coping, and referring those in need for ongoing
treatment.189
In low-income countries with scarce existing mental
health resources, it can be particularly challenging to
implement a mental health response following a
disaster. The initial disaster response may come from
international organizations and other groups from
outside the impacted community. There is therefore a
risk that interventions will not be sustainable after the
acute response ends and international aid is withdrawn
as well as a risk that the interventions will not be
culturally relevant and acceptable to the community.
On the other hand, disasters may provide an oppor-
tunity to examine and strengthen mental health systems
so that services meet the needs of the community and
remain available in the long term. Non-governmental
organizations should not circumvent local govern-
ments and should seek input from local stakeholders.
Governmental agencies and NGOs should build con-
sensus and coordinate efforts to avoid duplication of
services. The mental health workforce should be
developed with training programs. Mental health
services should be embedded into existing community
structures, including general hospitals and primary care
clinics, and systems for ongoing care and follow-up
should be established.190 Special attention should be
paid to the needs of children in the wake of cata-
strophic events. UNICEF, for example, has helped
create Child Friendly Spaces to allow opportunities for
recreation and social support and has also called for
more investment in early childhood education, nutri-
tion, trauma-focused supports in school, school con-
struction, and protection of children against
exploitation.191
Conclusions
High-income and low- and middle-income countries
face challenges in implementing community-based
mental health programs. Resource limitations exist
everywhere but are profound in low income countries.
382
There is growing recognition of the problem and there
are ongoing efforts to set research priorities and
develop evidence-based and culturally sensitive solu-
tions. Some global mental health initiatives have
grown out of response to catastrophic events; disasters
do provide an opportunity to reassess the mental health
system as a whole and make long-term sustainable
changes. More research is needed on meeting the
particular mental health needs of children around
the world.
The Future of Pediatric Mental Health
Given that approximately two-thirds of children and
adolescents with mental illness in the United States
never receive the mental health services they need the
time is now to change course and undo this devastating
health disparity. The research literature clearly conveys
that our current state of community mental health
services for children, adolescents, and their families are
woefully insufficient and fiscally fraile. However,
amidst this bleak outlook there are sparkles of hope
and we may possibly be on the brink of changing
course.
Because of the Affordable Care Act, mental health
and substance abuse disorders are finally deemed
essential health benefits. Because of Mental Health
Parity laws, evaluation and management codes for
psychiatric care have been implemented, billing codes
are based on the complexity of the patient visit just like
every other medical subspecialty and course and length
of treatment restrictions have been lifted. Numerous,
efficacious evidenced-based treatment modalities have
been designed, implemented, and proven to have
positive outcome measures for a wide range of
psychopathologies and familial, social, and environ-
mental complexities. Even funding streams and infra-
structure have been examined and demonstrated
sustainability at County and State levels. Innovations
in service delivery models including technology and
collaborative care have emerged and found footing to
reach children and families in their natural settings to
enhance engagement in services, decrease stigma, and
deliver optimal care. We may still have a workforce
shortage but what is encouraging is that with the tools
and our knowledge base we could be poised to design
and launch a community mental health system of care
that provides appropriate access and quality of mental
health care for children and families.
Curr Probl Pediatr Adolesc Health Care, November 2016
 Mental health is defined as “a state of well-being in
which every individual realizes his or her own poten-
tial, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a
contribution to her or his community”.192 Wellness is a
core human desire and need. Universal prevention,
early identification and intervention coupled with
familial and community social capitol promotes well-
ness.193 If every Pediatric Community Mental Health
System in every county and every state was built with
this premise and continuum there would be a con-
ceptual framework shift from mental illness to mental
wellness and barriers to treatment would begin to
break down.
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