In Part I of this post,
I discussed the policy implications of recent research from Duke
University showing a clear link between mental disorders in children
and their criminal activity as adults. I particularly focused on the
impact quality child care and poverty reduction can have as a means of
improving mental health—and thus, potentially prevent crime. Part II,
which focuses on education, health care, and the juvenile justice
system, follows below.

But a high-quality continuum of mental health services can’t only
engage with preschoolers. The reality of life is that people develop at
different rates, and the kid who’s quiet at age 3 can become a
hell-raiser at age 9. As such, schools have become a particularly
important site of diagnosing and treating mental health problems among
children.

For all the problems public schools face today, there has been some
progress on the mental health front. The Substance Abuse and Mental
Health Services Administration (SAMHSA) reports that 70 to 80 percent
of children who receive mental health services get the aid from
school-based mental health service providers (e.g. guidance counselors,
school psychologists, etc). Many schools have coordinated programs of
education, observation, and counseling that partner up with community
health experts.

But there’s still a ways to go. The American School Board reports that
there are around 1,700 school-based health centers in the United
States, a tiny fraction of the nation’s nearly 90,000 public schools.
There are many reasons for the relatively small number of centers
including the basic difficulties that come with implementing what
experts call an "ecological" model of mental health. This is a fancy
way of saying that schools that are serious about mental health can’t
just have mental health resources; they must integrate those
resources—educational materials, counselors, information, activities,
etc—into the every day school environment (e.g. classes, discipline,
etc).

This is, as you might imagine, a costly undertaking, and research from
SAMHSA has found that low-income and minority schools are far less
likely to have mental health programs in place. Those that do often
have very limited programs.

Making things worse is the fact that the lion’s share of funding for
school mental health services is highly fragmented. The dollars come
from disparate sources like state pools, the Individual with
Disabilities Education Act, the Safe and Drug-Free Schools and
Communities Program, the Elementary and Secondary Education Act of
1965, and even Medicaid and SCHIP. Dealing with these different funding
streams–and the requirements attached to each–inflates the
administrative overhead needed to manage funding.

A SAMHSA survey found that almost 50 percent of schools cite the
complexity of multiple funding sources and restrictions on the types of
services as barriers to providing kids with care. The work of schools
would be a whole lot easier if funding was streamlined and consistent.
A fractured system places extra burdens on already struggling
institutions.

So where does health care fit into all this? Somewhat predictably,
research shows that children with better access to health care are more
likely to receive the mental health services that they need. The Urban
Institute has shown that “44.9 percent of Medicaid/SCHIP children with
reported emotional or behavioral problems used a mental health service,
about the same as children with other (mostly private) insurance (41.0
percent), but over three times as high as uninsured children (13.7
percent)." Health coverage gives more kids access to more services.

But "more health care" is no silver bullet. Consider the fact that
Columbia University research has shown that 79 percent of children with
private insurance have unmet mental health needs. The problem goes
beyond health coverage. 

That’s because, while coverage provides access to care, it means little
if the care is lacking—and pediatrics has a long way to go before
embracing an effective mental health model. In a 2004 article in
Pediatrics, Edward Schor, M.D. notes that preventive mental, emotional,
and behavioral care “receives little emphasis in pediatric training,
reluctant consideration by insurers, and rare attention from
researchers.” Writing for the Commonwealth Fund, Schor summarizes some
of his most striking findings:

• 94 percent of American parents report unmet parenting guidance, education, or screening needs by pediatric clinicians.
• Minority or economically disadvantaged parents are two to four
  times more likely to express dissatisfaction with the growth and
  development care their children receive than white, non-poor, insured
  families.
• In a national survey, 36 percent of parents of young children
  reported not discussing significant specific, recommended child health
  issues with their pediatricians.
• In one large study, 40 percent of parents of children covered by
  Medicaid were not asked by pediatricians whether they had concerns
  about their children’s learning, development, or behavior.
• The official schedule for pediatriciac visits is based mainly on
  immunization requirements, not the pediatricians’ traditional holistic
  consideration of a child’s health and concern for children’s
  development.
• Children attend fewer than one-half of the recommended well-child visits, even when there are no financial barriers.

“Well-being” should be part our understanding of child health,” says
Schor, and he recommends creating  an official manual of pediatrics
best practices and a more focused sequence of pediatrician visits
centered on different themes (e.g. “Understanding Your Child”). Perhaps
most importantly, Schor notes that “early childcare and special
education, welfare, foster care, and education” are “natural partners
for pediatrics and pediatricians and should be enlisted not only in
caring for individual children but also in formulating national
policies that define the desired outcomes of, and thus support the need
for, high-quality well-child care." In other words, we need to address
childrens’ mental health through a coordinated response that winds
through the entire social safety net.

Schor is exactly right about this collaborative approach—not only
because mental health extends beyond medicine, but because
pediatricians need all the help they can get. According to numbers
Maggie has previously pulled from Merritt, Hawkins & Associates, a
national consulting firm that specializes in recruiting physicians,
pediatricians are some of the lowest paid physicians across various
specialties. Given the debt associated with medical school and the
mega-bucks that other doctors can pull in—the average orthopedic
surgeon in 2007 made more than 2.5 times as much as the average
pediatrician—there is an imperative for pediatricians to see as many
patients as possible. This is not conducive to a holistic, integrated
approach to child well-being. For pediatricians to effectively
participate in a more coordinated wellness system, the salary crunch
needs to be resolved. 

But even if pediatricians were to suddenly become millionaires, nothing
would change unless the other factors—child care, poverty, and
education—also changed for the better. Similarly, the last piece of the
puzzle in thinking about crime prevention—the criminal justice system
itself—would have to refocus on youth rehabilitation for this
collaborative continuum to really work. Right now, it’s only making things worse.

In 2002, the National
Institute for Mental Health funded the largest study to ever look at
mental disorders in juvenile offenders and found that 65 percent of
boys and 75 percent of girls in juvenile detention have at least one
mental disorder. With the prevalence of mental disorders among kids in
the juvenile justice system more than three times higher than it is for
other children, you’d think that juvenile justice would double as a
gateway to rehabilitative mental health services. Not so. 

The penchant America shows for unproductive incarceration in adults
also holds true for children. For example, the National Center on
Substance Abuse at Columbia University found that of the 2.4 million
juvenile arrests in 2000, 1.9 million involved substance abuse and
addiction but that only 68,600 of those arrested received any substance
abuse treatment. According to the Campaign for Youth Justice, only 11
percent of jails that house juveniles provide for special education
services—despite the fact that some 30 percent of inmates younger than
24 have learning disabilities.

Perhaps the worst offense of the system is its conflation of young
offenders with adults. Throughout the 1990s, forty-five states passed
reforms that made it easier for children to be tried in the adult
criminal justice system. Since then, most children have been detained
pre-trial in adult jails rather than juvenile detention centers, where
they are at a much greater risk of physical and sexual assault.

Obviously, jail is no place for children—especially disturbed ones. A
November report from the CDC found that involving children in the adult
criminal justice system makes them more violent. As the director of the
Georgetown Center for Juvenile Justice Reform told the Washington Post,
"you couldn’t ask for any worse results. We’re getting faster
recidivism for more serious crimes." In Florida, for example, youths
sent to the adult system had 34 percent more felony re-arrests than
those retained as juveniles, despite having equivalent crime records.
If pediatrics ignores mental health, the criminal justice system
actually worsens it—and with the infrastructure for child welfare
already so precarious, that’s the last thing we need.

Unfortunately, in recent years juvenile justice has seen the same
amount of national political attention as general crime has—that is to
say, very little. Today politicians keep mum on crime because they
don’t quite know what to say. They can’t stir fear, because crime is
low. They can’t take credit for the crime drop, because no one knows
why it happened. What’s a vote-hungry politico to do?

He might start by embracing the Duke research and its policy
implications. Childhood mental disorders are complex dilemmas, tied to
a variety of social circumstances—and if they predict crime, then our
thinking about crime should be commensurately complex.

That means moving beyond our obsession with enforcement and punishment.
Instead, we should think abut how child welfare translates into adult
behavior—and how our social policies can complement each other to
promote healthy development. True, there’s no guarantee of total
success.  No doubt, there will always be criminals among us.  But what
better time to roll out a full rethinking of crime prevention than when
the crime rate is low—and thus the wiggle room for trial-and-error is
high?

At the very least, we’ll see a stronger social safety net that will
benefit everyone. And at best, a generation will come of age in a
society that’s finally taken measures to ensure them a healthy future.