Thirteen years after a landmark U.S. Surgeon General's report characterized the lack of adequate mental health services for children as a "serious concern," those services remain widely unavailable in low-income, inner-city neighborhoods. Some 80% of uninsured youth who require treatment don't receive any, and services for the other 20% are often of questionable quality. Meanwhile, the nation's mental health system itself remains "fragmented and disconnected." Referencing these bleak facts in his presentation at the University of Pennsylvania, Marc Atkins, PhD, underscored the serious problems in the national mental health system and his current research exploring potentially new ways to address them.
"This is an unprecedented time for children's mental health," he said. "It's only been in the last ten years or so that it's really gotten on the national map -- still, only one in five of these kids who need mental health services get any service at all."
Radically different approach
A professor of psychology and psychiatry at the University of Illinois Chicago, Atkins is also Director of the University's LINKS Center at the Institute for Juvenile Research, which is funded by the National Institute of Mental Health and Medicaid. In a project that draws on a diverse group of academic researchers from across the country, LINKS is testing a radically different approach for mental health service delivery for youth in high-poverty urban areas. Its primary target is elementary school classrooms.
Atkins’ work is also focused on breaking down the isolation in which the mental health professionals have traditionally practiced.
"We need to stop thinking about prevention as a silo. We need to make connections between mental health-related prevention, promotion, treatment and maintenance. It's all part of the same continuum but the mental health system is not organized that way," he told the seminar sponsored by Penn's Leonard Davis Institute of Health Economics (LDI) and Center for Mental Health Policy and Services Research (CMHPSR).
Seven high-poverty schools
In a multi-year research project, the LINKS Center's Links to Learning program works with seven high-poverty Chicago schools to test a new system that integrates mental health prevention and intervention services into the daily fabric of school life.
"Urban schools today are overcrowded and plagued by mental health problems, as well as safety and violence issues, shortages of resources, deteriorating physical plants, the lack of things as fundamental as up-to-date textbooks and teacher burnout," said Atkins. "We asked ourselves 'why is the mental health community sitting back in their clinics and waiting for these kids and families not to show?"
Atkins acknowledged that schools are not a traditional setting for mental health facilities, "nor are they the place that we would logically think kids ought to be getting their mental health services." However, he noted, schools serve as a unique link between home and community environments and have an inherent capacity to support mental health.
"The question we asked," said Atkins, "is 'What is the mission of that particular setting? How does that mission advance kids' mental health and how can we re-allocate mental health resources to support that?'"
Embedded mental health support
The Links model focuses on creating an intervention using local resources within schools to minimize disruption and embed mental health support in the context of the classroom. The intervention also trains select teachers and parent advocates to serve as "key opinion leaders" and incentivizes faculty members to participate.
The types of mental health interventions used take two forms: "universal" interventions are implemented class-wide and "targeted" interventions are implemented only for children with referrals for mental health disorders. Both strategies provide an alternative to traditional, clinic-based mental health services, which Atkins said are often "difficult to access and ineffective at addressing problems."
Universal interventions, such as the Good Behavior Game (GBG) or Peer Assisted Learning (PAL), empower children by establishing them as co-managers of learning and classroom behavior. In GBG, classrooms are divided into teams and gain or lose points based on behavior. Successful teams are rewarded with praise, while unsuccessful teams undergo a review of disruptive behaviors. PAL operates on a smaller scale, dividing students into pairs based on learning ability. Students build self-esteem and social skills as they collaborate on academic work. These strategies allow children "to influence one another in a positive direction toward increased prosocial interactions."
On an individual level, targeted interventions are implemented for children with disruptive classroom behavior. Targeted intervention programs, such as the Daily Report Card or Good News Notes, develop individualized goals based on each child’s needs and provide students and parents with frequent feedback.
While Atkins feels that these interventions are effective at improving classroom and home behavior, he acknowledges that they are not sufficient alone and that his team is investigating ways to enhance the model.
Atkins believes that collaboration of parents and teachers has increased the likelihood of intervention use. "The concept was to get teachers, parents, and mental health providers all united around the concept of learning," he said. "We wanted to see if we could link community mental health resources with indigenous resources in school."
The Links model has been on the ground for three years and the results have been promising. Atkins said overall, it has been successful in improving academic performance, engagement, and behavior among the study group and has also demonstrated that school-based models can be effective.
While Atkins is hopeful about the future of mental health reform, he emphasized that there is a long way to go: "The changes going on with health care reform are setting the stage. Prevention is an enormously important issue, but we in mental health are behind the curve."