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Presidential Address: Partnering for the World’s Children Paramjit T. Joshi,
I
t is indeed a distinct honor and privilege for me to stand before this very august audience to present the plenary address. I am deeply humbled and extremely grateful for having been given this chance to be the incoming president of the American Academy of Child and Adolescent Psychiatry (AACAP). I stand before you at a historic moment for our beloved Academy: its 60th birthday. I would like to share with you a little bit about my journey, my vision for the Academy, and the changes, challenges, and opportunities that face us—those that we anticipate and others that we will be surprised by, but undoubtedly prepared for. The Academy has grown tremendously over the last 6 decades to become what it is today—a robust, thriving, vibrant, and wonderful organization that I call my “professional home.” I am proud to have been a member for at least half that time. However, my journey started in postcolonial, post-British India where I was born and raised. The historical events around that time had a major and lasting impact on my family that continued to reverberate in our collective psyche as I was growing up. While my mother’s family was well settled and resided in Pakistan, my father’s family lived in India. During the partition of the 2 countries, there was a massive movement of people across the border and my mother’s family was uprooted and forced to move to India—essentially refugees, having left everything behind in Pakistan, re-settling, and starting from a scratch—all too familiar, I might say, for many of us who are first-generation immigrants in the United States. During my medical school years, I was most happy on my pediatric rotation, developed a love for working with children, and subsequently completed a residency and board certification in pediatrics. However, in addition to my interest in the medical well-being of my patients, I was
MD
always intrigued by my patients’ life stories, the social and psychological issues that mattered to them, and how those issues influenced them as individuals and the impact they had on the course of my patients’ medical illnesses. At the time, I was completely unaware of the field of psychiatry, let alone child and adolescent psychiatry. However, after moving to the United States, many options suddenly became available to me, and, given my innate interest in the psychological and mental lives of my pediatric patients, I decided to pursue the field of child and adolescent psychiatry. In preparing for this plenary, I afforded myself the opportunity to learn a little more about the origins of our field and the founding of our Academy in 1953. William Healy, MD, a pioneer psychiatrist and criminologist, established the first child guidance clinic in the United States in 1909, and was an early advocate and promoter of both the interdisciplinary “team approach” and the “child’s own story” in treatment and research.1 Among his contributions to the field of criminology are his book The Individual Delinquent and his “multifactor theory” of delinquency, which broadened the field and moved it away from European criminology’s stress on genetic factors alone.2 Healy developed an elaborate methodology for the complete study of the offender by a variety of specialists. The founders of our Academy and each of the past presidents have moved us forward, inspired us with their leadership, and enriched us—such that today our Academy is a leading voice in the world when it comes to child and adolescent psychiatry. Our members are uniquely qualified to integrate knowledge about human behavior and development from biological, psychological, familial, social, and cultural perspectives with scientific, humanistic, and collaborative approaches to the diagnosis, treatment, and promotion of mental
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health in children and adolescents, and to uphold the mission of AACAP.3 But what does the future look like for us as child and adolescent psychiatrists and for our Academy? In the decade to come, our nation will experience continued population growth and an increasing need for mental health care and the well-being of our children and their families. We will also welcome a trend whereby we will continue to experience shifting trends in increased public knowledge and more accurate perception of mental illness. We are certainly on the cusp of great change in our health care system, which begs the following questions: What will the delivery of mental health services look like in the near future? Will the treatments be evidencebased? How much will they cost? Will our patients get better? How will these outcomes be measured?4 A recent study revealed that the total number of primary care visits for persons with a psychiatric diagnosis increased significantly albeit faster for youth than for adults, but that, at the same time, visits to a psychiatrist also increased significantly faster for youth than for adults. Therefore, compared to mental health care for adults, that for young people has increased more rapidly and has coincided with increased psychotropic medication use.5 With the public being more educated, they too have come to demand and expect more from their providers, and while they are much more knowledgeable about medication choices, they are less so about evidence-based psychotherapies. In addition, the various advocacy groups have been relentless in providing support to patients and their families, preparing and disseminating educational materials, lobbying politicians, and partnering with us to level the playing field when it comes to mental and somatic health. As was the case with cancer, HIV, and other infectious diseases that have been stigmatizing over the decades, scientific discoveries and innovative treatments that work have helped to put a dent in the issue of erasing stigma.4 As we have learned, much of the pharmacological treatment is provided by a nonpsychiatrist physician. This in part reflects the growing problem of workforce shortages and long wait times to be seen by a child and adolescent psychiatrist. It is estimated that there will be a severe physician shortage in the United States in the next few years across all disciplines. Although there are new medical schools that have opened graduate medical education (GME) funding, residency training has remained stagnant if not decreased. 4
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This is quite a pressing issue that will need to be urgently addressed. It is ironic that although the Affordable Care Act (ACA) will allow many uninsured persons to receive care, there will be far fewer providers that they will be able to access. The stakes are rather high, with mental illness having a significant effect on the country’s youth, their families, and our communities. In a recent study of mental health policy, Richard Frank and Sherry Glied assessed whether people with a mental illness were better off now than 50 years earlier. They answered that question with the name of their monograph: “Better, but Not Well.”6 Although health reform creates opportunities to improve care for many Americans, the safety net for individuals with the most serious mental illness is much stressed. The hardest hit are children’s mental health services despite the fact that children’s mental health problems have been called “the major chronic diseases of childhood.” Over the next decade, we cannot underestimate the power and the magnitude of 2 forces that have come to bear on us, and the change that they will bring. The first is the rapidly rising cost of health care, and the second is the increasing pace and momentum of scientific discovery. The former has resulted in health care reform initiatives—such as the Patient Protection and Affordable Care Act, a process that will change the way in which health care is provided and financed. The latter will lead to changes in our understanding of the mind, brain, and behavior, and how scientific advances will transform our ability to treat mental disorders. I suggest that we embrace these changes; they will ultimately improve the quality and status of our profession. Toward that end, we should make every effort to learn and to educate our members about what to expect as the health care reform process unfolds, and how it will affect current models of care, professional roles, and methods of reimbursement. A large majority of mental illnesses seen in adults have their origins in childhood and adolescence, but the average lag time to treatment is 8 to 10 years. Early diagnosis and treatment of these disorders will thus have an impact on their prevalence and course in adult life. According to the Centers for Disease Control and Prevention (CDC),7 just 1 in 5 children either currently or at some point during their lifetime will have had a seriously debilitating mental disorder, but only about 20% of these youth receive treatment. More youth and young adults continue to die by
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suicide, and 90% of those who die by suicide have a mental illness (diagnosed before death). So, despite recent advances, we have not been able to make much of a dent in the rates of suicide. Earlier this year in June, President Obama held a White House Summit on mental health, looking for solutions regarding how best to address the pressing needs of the mentally ill in this country, which I was fortunate to attend. This was prompted by a public outcry in light of a spate of horrific public massacres. Now is the time for leadership, and, as we form task forces, forums, and expert panels to respond to the shootings such as in Newtown, Connecticut, a discussion must take place about how we can ensure the mental health and well-being of our children. If it does not, we will have failed both the children who perished in these tragedies and those whom we are fortunate enough to still have in our care. We have a social and moral imperative to support the 1 in 5 children who will need access to care. Physically and mentally healthy children are more likely to become physically and mentally healthy adults. These children will grow up and enter our armed forces, our intelligence communities, our workforces, and our governments. Currently, we are taking care of organ systems instead of the total patient. The future lies in transforming the understanding and treatment of mental illnesses through basic and clinical research; paving the way for prevention, recovery, and cure by looking at the pathophysiology, predictive biomarkers, and preemptive interventions; and viewing mental illnesses as developmental disorders. We need to shift our dialogue about children’s mental health and think differently. In medical school, we were taught to think backward—to diagnose things after they occur, to cure things after they happen. But what if we flipped the model? What if we could look forward, anticipate, and intervene before disease begins? Ultimately, it is not just about keeping our children healthy, but also about creating a society of healthy adults. As pediatricians and child and adolescent psychiatrists, we are already trained to think forward. We think developmentally: what happens at 2 months, 4 months, 8 months, and 2 years? And how can we prevent, screen, and anticipate? Nowhere is that approach more needed than in ensuring the mental health of our children.4 I propose that we take the following steps:
1) Take pride in what we have accomplished as child and adolescent psychiatrists, and in who we are. Our ongoing commitment to the evidencebased practice of our medical subspecialty, the application of science to our practice, and perseverance in improving our diagnostic and therapeutic skills are all important achievements. It is this commitment that makes us very special and unique, and we all share enormous pride in the outstanding members of our Academy who have made extraordinary contributions to our practice and to the care and understanding of children and adolescents around the world. Work in areas ranging from evidence-based psychotherapy studies to pharmacology to genetics and the interplay between environmental and genetic factors have all helped to advance our knowledge and practice. 2) Accept that mental health is a children’s health issue. The 1 in 5 children in the United States who suffer from a mental illness encompasses a wide range of diagnoses. Of the 15 million children affected by such conditions, only 20% ever receive treatment. This is especially sobering when we consider that, by age 14 years, half of all lifetime diagnoses of mental illness will begin manifesting, and that 75% will show up by age 24. In the face of these numbers, children and families urgently need better ways to get the necessary support.7 3) Treat the child, not the diagnosis. A diagnosis is, at best, a start, not an end. This is especially true in mental health. Children with the same diagnosis can exhibit profoundly different behaviors and can need very different approaches. To be effective, the treatment of mental health in children must be individualized for the child and his or her family, and it must include an understanding of environmental, social, and developmental factors. We should not be satisfied merely with treating symptoms in patients with mental illness, but also with improving their overall well-being. There are many studies that have shown that positive traits such as optimism and social engagement are associated with a significant decrease in mortality, and I think that, as child and adolescent psychiatrists, we
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suggests to us that these may not be distinct diseases, as we have thought for so long.”8
are in a good position to incorporate these into psychotherapy and psychosocial interventions. 4) Start screening early and ensure access to care. Even with the most advanced approaches, real change cannot be achieved if the significant shortages in pediatric mental health providers are not addressed. This is a profound failing in a health care system that is supposed to ensure that children receive the best available care. We need to continue to advocate for appropriate funding for child mental health specialists, including loan repayment, and urge lawmakers in Congress to re-enact the bill that was first introduced in the Budget Act of 1997. 5) Do school mental health right. Although the gaps in children’s mental healthcare are huge, there is also reason for hope. President Obama’s proposals following the tragedy in Newtown include significant expansion of school-based mental health services. Done right, this could be a significant benefit and could also lead to improving educational outcomes. Funds for school-based mental health were introduced in HR bill 751 in the 112th Congress, and we collectively need to advocate for such appropriations moving forward. 6) Advocate for and invest in our future research efforts. Technological breakthroughs during the past few years have helped us to understand, identify, and intervene in many medical issues before they manifest symptoms. Any discussion of the biological basis of psychiatric disorders must include genetics. Indeed, we are beginning to fit new pieces into the puzzle of how genetic mutations influence brain development. The largest genome-wide study of its kind from the multinational CrossDisorder Group of the Psychiatric Genomics Consortium (PGC), published earlier this year in Nature Genetics, revealed the extent of genetic overlap among 5 major psychiatric disorders—a potential boon for research and eventually treatment. To quote Patrick Sullivan and co–senior author Kenneth Kendler, “It allows us an unprecedented look ’under the hood’ at what the genetic data tell us about these 5 important psychiatric disorders. The clear overlap in genetic risk for these disorders
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In 2009, the National Institute of Mental Health (NIMH) launched the Research Domain Criteria (RDoC) project, which is developing a mental disorders classification system for research, based more on underlying causes than on symptoms. It is hoped that the RDoC project will go beyond our current disorder classification system to look at the behavior systems and fundamental brain circuits that cut across many disorders.9 A recent study of adults with depression treated with either cognitive behavioral therapy or an antidepressant medication found that persons who started with below-average baseline activity in the right anterior insula responded well to cognitive behavioral therapy, but not to the antidepressant and vice versa.10 This opens the possibility for personalized treatment with the potential that one could predict a depressed person’s response to specific treatments from the baseline activity in the right anterior insula. These results lead us to believe that neural circuits disturbed by psychiatric disorders are likely to be very complex, and that psychotherapy is a biological treatment that can produce lasting, detectable physical changes in our brain, much as learning does, and that the effects of psychotherapy can be studied empirically. These are all exciting, cutting-edge, and innovative ideas, and the future of our field in many ways lies in the discoveries and treatments that are yet to come. The research that occasions these developments may not just enhance our ability to make diagnoses, but may fundamentally redefine the nosology of mental disorders. The history of medicine is punctuated by certain inflection points that mark transformative changes. We are certainly approaching another such moment in our profession’s development, and it is just around the corner: the Affordable Care Act—both a boon for our field and an opportunity that we cannot and must not pass up. I cannot help but reminisce about the time when we faced another wind of force, “Managed Care,” and the impact that it had and continues to have on our field and how we practice today. Mental health care has been greatly enhanced by the passage of the Patient Protection and Affordable Care Act (ACA), which includes mental health within its changes to health care. This hard-fought piece of legislation might end up being a game changer for
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mental health. The inclusion of mental health will lead to profound changes that will play out over the next generation. However, any assessment of the state of America’s mental health system must begin with a realization that we have begun to take big steps away from an approach that was both separate and unequal. The major challenges facing us are, first, whether including mental health in health care can be done sensibly, and second, whether the portions of the mental health safety net that have value can be sustained. Inclusion creates great opportunities that we can seize or let slip away. How do we accomplish this? A first major challenge for the next decade is to integrate basic mental health care into primary care, which could be a core element of getting mental health parity right. It can be done well, improving health and reducing costs, but barriers must be addressed. We know that most children are treated by their pediatricians or other primary care practitioners rather than by child and adolescent psychiatrists. Improving basic mental health care in primary care is a huge need and opportunity, and a responsibility that we need to embrace and take the lead on; for if we do not, someone else will. I am delighted that some of our own members have already spearheaded successful model programs in a number of states around the country. At the same time we also need to ensure cross-disciplinary assessment for children, which includes pediatrics, psychology/psychiatry, social work, physical medicine and rehabilitation, neuropsychology, and neurology. Furthermore, standardization and integration of mental healthcare such as electronic medical records and integrated databases will be important. A recent monograph published by the Institute of Medicine, Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress and Possibilities, highlights prevention in psychiatry—in childhood and across the lifespan.11 The future can and should be brighter for our patients and their families. Lastly, I want to share the elements of my Presidential Initiative. The goal of each President is to leave the Academy with a contribution that will serve well the field, its members, and ultimately our patients and their families, and thereby leave the Academy a better organization. Given the fact that there is such a dearth of child and adolescent psychiatrists in the world, it is imperative that we at AACAP share what we
have in the way of goodwill, resources, and our many materials with our colleagues around the world. Although we celebrate and pride ourselves on the unique aspects of each culture and country that define and separate us, there is much more that unites us. The mental well-being of all children and adolescents around the world is a common goal that we share. As has been said, “To whom much is given, much is expected,” so I also feel this to be a moral imperative that we at AACAP have an obligation to embrace our colleagues globally, and to learn from and share with each other. We at AACAP can benefit so much from other international organizations and their members. This collaboration can only add to the richness of AACAP and its mission and members. The Academy has grown so much over the past 60 years and now has a strong global influence that extends beyond our shores to other nations. Our Academy is quite diverse in its membership, but we can and should appeal to an even broader group of colleagues with opportunities for everybody, especially our younger colleagues who are the future of our field. With this in mind, I decided to title my presidential initiative, “Partnering for the World’s Children.” Perhaps it is my background and earlier life experiences both personally and professionally that have attracted me to the global aspect of child and adolescent psychiatry (CAP). In the end, it is our personal experiences that shape us and define who we are as individuals. I feel so fortunate to have colleagues such as Joaquin Fuentes, YoungShin Kim, Howard Lui, Bennett Leventhal, and Norbert Skokauskas on the Steering Committee, whose role it is to be a sounding board, to advise me, and to review the recommendations that will be made by the various AACAP committees that have been tasked by me to look at 4 major areas: membership structure, educational materials, the AACAP website, and international relations. I hope that the fruits of this initiative will lead to enhancing AACAP’s relationship with international organizations, collaborations, and sharing of educational resources, making AACAP’s website more accessible to international colleagues, providing support for international medical graduates, and examining AACAP’s membership categories. I would like to use existing relationships between AACAP and other child psychiatry organizations to facilitate opportunities for our members and to foster the
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global work of the organizations. No single organization can do it all, and each has its own resources, programs, and meetings; and it would be wonderful if we could support each other, share, and promote our various efforts. In conclusion I would like to say that, although some of the issues that I have raised do not necessarily suggest “easy fixes,” mental health concerns are coming out of the shadows at a time of major change in health care, and we need to seize all opportunities to improve health care for millions of children. Sometimes it is very hard to remind the public—and even ourselves—that we are living in a moment of unprecedented scientific progress and with an array of therapeutic interventions with extraordinary effectiveness. It is easy to lose sight of these positive aspects of our discipline, but we find ourselves at the right moment in time, have the scientific momentum, public health imperative, and moral
imperative—and there is nothing to be defensive or shy about. I am very optimistic that together we can all work to advance our field, preserve our identity, and provide the best care that we can to our patients. To do this, we must be able to collaborate, be intellectually and politically active, remain well organized, and share common goals and agendas, so we can speak with one voice on the world stage. & Dr. Joshi is with Children’s National Medical Center and is president of the American Academy of Child and Adolescent Psychiatry, 2013e2015. A version of this Presidential Address was delivered on October 23, 2013, at the 60th Annual Meeting of the American Academy of Child and Adolescent Psychiatry in Orlando, Florida. Disclosure: Dr. Joshi is a Psychiatry Director of the American Board of Psychiatry and Neurology (ABPN). 0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2013.10.009
REFERENCES 1. Snodgrass J. William Healey (1869–1963): Pioneer child psychiatrist and criminologist. J Hist Behav Sci. 1984;20:332-339. 2. Healey W. The Individual Delinquent: A Textbook of Diagnosis and Prognosis for All Concerned Understanding Offenders. Boston: Little, Brown; 1959. 3. AACAP Mission Statement [adopted by Council October 29, 1994; amended and approved by Council June 27, 2010]. Available at: http://www.aacap.org/aacap/About_Us/Mission_Statement.aspx. Accessed November 20, 2013. 4. Joshi P. Mental health services for children and adolescents: Challenges and Opportunities [editorial]; JAMA Psychiatry. (in press). 5. Olfson M, Blanco C, Wang S, Laje G, Correll C. National trends in mental health care of children, adolescents and adults by officebased physicians. JAMA Psychiatry. (in press). 6. Frank RG, Glied SA. Better But Not Well: Mental Health Policy in the US Since 1950. Baltimore, MD: Johns Hopkins University Press; 2006.
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7. Centers for Disease Control and Prevention. Mental health surveillance among children—United States, 2005–2011. Morbid Mortal Wkly Rep. 2013;62 (Suppl):1-35. 8. Sullivan P, Kendler K. Cross Disorder Group of the Psychiatric Genomic Consortium: genetic relationship between 5 psychiatric disorders estimated from genome-wide SNP’s. Nature Genet. 2013;45:984-994. 9. Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010;167:748-751. 10. McGrath CL, Kelley ME, Holtzheimer PE, et al. A neuroimaging treatment selection biomarker for major depressive disorder. JAMA Psychiatry. 2013;70:821-829. 11. Institute of Medicine of the National Academies. Preventing mental, emotional, and behavioral disorders among young people— progress and possibilities: Institute of Medicine of the National Academies. Consensus Report March 12, 2009. Washington DC: National Academies Press;2009.
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Presidential Address: Partnering for the World’s Children Paramjit T. Joshi,
I
t is indeed a distinct honor and privilege for me to stand before this very august audience to present the plenary address. I am deeply humbled and extremely grateful for having been given this chance to be the incoming president of the American Academy of Child and Adolescent Psychiatry (AACAP). I stand before you at a historic moment for our beloved Academy: its 60th birthday. I would like to share with you a little bit about my journey, my vision for the Academy, and the changes, challenges, and opportunities that face us—those that we anticipate and others that we will be surprised by, but undoubtedly prepared for. The Academy has grown tremendously over the last 6 decades to become what it is today—a robust, thriving, vibrant, and wonderful organization that I call my “professional home.” I am proud to have been a member for at least half that time. However, my journey started in postcolonial, post-British India where I was born and raised. The historical events around that time had a major and lasting impact on my family that continued to reverberate in our collective psyche as I was growing up. While my mother’s family was well settled and resided in Pakistan, my father’s family lived in India. During the partition of the 2 countries, there was a massive movement of people across the border and my mother’s family was uprooted and forced to move to India—essentially refugees, having left everything behind in Pakistan, re-settling, and starting from a scratch—all too familiar, I might say, for many of us who are first-generation immigrants in the United States. During my medical school years, I was most happy on my pediatric rotation, developed a love for working with children, and subsequently completed a residency and board certification in pediatrics. However, in addition to my interest in the medical well-being of my patients, I was
MD
always intrigued by my patients’ life stories, the social and psychological issues that mattered to them, and how those issues influenced them as individuals and the impact they had on the course of my patients’ medical illnesses. At the time, I was completely unaware of the field of psychiatry, let alone child and adolescent psychiatry. However, after moving to the United States, many options suddenly became available to me, and, given my innate interest in the psychological and mental lives of my pediatric patients, I decided to pursue the field of child and adolescent psychiatry. In preparing for this plenary, I afforded myself the opportunity to learn a little more about the origins of our field and the founding of our Academy in 1953. William Healy, MD, a pioneer psychiatrist and criminologist, established the first child guidance clinic in the United States in 1909, and was an early advocate and promoter of both the interdisciplinary “team approach” and the “child’s own story” in treatment and research.1 Among his contributions to the field of criminology are his book The Individual Delinquent and his “multifactor theory” of delinquency, which broadened the field and moved it away from European criminology’s stress on genetic factors alone.2 Healy developed an elaborate methodology for the complete study of the offender by a variety of specialists. The founders of our Academy and each of the past presidents have moved us forward, inspired us with their leadership, and enriched us—such that today our Academy is a leading voice in the world when it comes to child and adolescent psychiatry. Our members are uniquely qualified to integrate knowledge about human behavior and development from biological, psychological, familial, social, and cultural perspectives with scientific, humanistic, and collaborative approaches to the diagnosis, treatment, and promotion of mental
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health in children and adolescents, and to uphold the mission of AACAP.3 But what does the future look like for us as child and adolescent psychiatrists and for our Academy? In the decade to come, our nation will experience continued population growth and an increasing need for mental health care and the well-being of our children and their families. We will also welcome a trend whereby we will continue to experience shifting trends in increased public knowledge and more accurate perception of mental illness. We are certainly on the cusp of great change in our health care system, which begs the following questions: What will the delivery of mental health services look like in the near future? Will the treatments be evidencebased? How much will they cost? Will our patients get better? How will these outcomes be measured?4 A recent study revealed that the total number of primary care visits for persons with a psychiatric diagnosis increased significantly albeit faster for youth than for adults, but that, at the same time, visits to a psychiatrist also increased significantly faster for youth than for adults. Therefore, compared to mental health care for adults, that for young people has increased more rapidly and has coincided with increased psychotropic medication use.5 With the public being more educated, they too have come to demand and expect more from their providers, and while they are much more knowledgeable about medication choices, they are less so about evidence-based psychotherapies. In addition, the various advocacy groups have been relentless in providing support to patients and their families, preparing and disseminating educational materials, lobbying politicians, and partnering with us to level the playing field when it comes to mental and somatic health. As was the case with cancer, HIV, and other infectious diseases that have been stigmatizing over the decades, scientific discoveries and innovative treatments that work have helped to put a dent in the issue of erasing stigma.4 As we have learned, much of the pharmacological treatment is provided by a nonpsychiatrist physician. This in part reflects the growing problem of workforce shortages and long wait times to be seen by a child and adolescent psychiatrist. It is estimated that there will be a severe physician shortage in the United States in the next few years across all disciplines. Although there are new medical schools that have opened graduate medical education (GME) funding, residency training has remained stagnant if not decreased. 4
www.jaacap.org
This is quite a pressing issue that will need to be urgently addressed. It is ironic that although the Affordable Care Act (ACA) will allow many uninsured persons to receive care, there will be far fewer providers that they will be able to access. The stakes are rather high, with mental illness having a significant effect on the country’s youth, their families, and our communities. In a recent study of mental health policy, Richard Frank and Sherry Glied assessed whether people with a mental illness were better off now than 50 years earlier. They answered that question with the name of their monograph: “Better, but Not Well.”6 Although health reform creates opportunities to improve care for many Americans, the safety net for individuals with the most serious mental illness is much stressed. The hardest hit are children’s mental health services despite the fact that children’s mental health problems have been called “the major chronic diseases of childhood.” Over the next decade, we cannot underestimate the power and the magnitude of 2 forces that have come to bear on us, and the change that they will bring. The first is the rapidly rising cost of health care, and the second is the increasing pace and momentum of scientific discovery. The former has resulted in health care reform initiatives—such as the Patient Protection and Affordable Care Act, a process that will change the way in which health care is provided and financed. The latter will lead to changes in our understanding of the mind, brain, and behavior, and how scientific advances will transform our ability to treat mental disorders. I suggest that we embrace these changes; they will ultimately improve the quality and status of our profession. Toward that end, we should make every effort to learn and to educate our members about what to expect as the health care reform process unfolds, and how it will affect current models of care, professional roles, and methods of reimbursement. A large majority of mental illnesses seen in adults have their origins in childhood and adolescence, but the average lag time to treatment is 8 to 10 years. Early diagnosis and treatment of these disorders will thus have an impact on their prevalence and course in adult life. According to the Centers for Disease Control and Prevention (CDC),7 just 1 in 5 children either currently or at some point during their lifetime will have had a seriously debilitating mental disorder, but only about 20% of these youth receive treatment. More youth and young adults continue to die by
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suicide, and 90% of those who die by suicide have a mental illness (diagnosed before death). So, despite recent advances, we have not been able to make much of a dent in the rates of suicide. Earlier this year in June, President Obama held a White House Summit on mental health, looking for solutions regarding how best to address the pressing needs of the mentally ill in this country, which I was fortunate to attend. This was prompted by a public outcry in light of a spate of horrific public massacres. Now is the time for leadership, and, as we form task forces, forums, and expert panels to respond to the shootings such as in Newtown, Connecticut, a discussion must take place about how we can ensure the mental health and well-being of our children. If it does not, we will have failed both the children who perished in these tragedies and those whom we are fortunate enough to still have in our care. We have a social and moral imperative to support the 1 in 5 children who will need access to care. Physically and mentally healthy children are more likely to become physically and mentally healthy adults. These children will grow up and enter our armed forces, our intelligence communities, our workforces, and our governments. Currently, we are taking care of organ systems instead of the total patient. The future lies in transforming the understanding and treatment of mental illnesses through basic and clinical research; paving the way for prevention, recovery, and cure by looking at the pathophysiology, predictive biomarkers, and preemptive interventions; and viewing mental illnesses as developmental disorders. We need to shift our dialogue about children’s mental health and think differently. In medical school, we were taught to think backward—to diagnose things after they occur, to cure things after they happen. But what if we flipped the model? What if we could look forward, anticipate, and intervene before disease begins? Ultimately, it is not just about keeping our children healthy, but also about creating a society of healthy adults. As pediatricians and child and adolescent psychiatrists, we are already trained to think forward. We think developmentally: what happens at 2 months, 4 months, 8 months, and 2 years? And how can we prevent, screen, and anticipate? Nowhere is that approach more needed than in ensuring the mental health of our children.4 I propose that we take the following steps:
1) Take pride in what we have accomplished as child and adolescent psychiatrists, and in who we are. Our ongoing commitment to the evidencebased practice of our medical subspecialty, the application of science to our practice, and perseverance in improving our diagnostic and therapeutic skills are all important achievements. It is this commitment that makes us very special and unique, and we all share enormous pride in the outstanding members of our Academy who have made extraordinary contributions to our practice and to the care and understanding of children and adolescents around the world. Work in areas ranging from evidence-based psychotherapy studies to pharmacology to genetics and the interplay between environmental and genetic factors have all helped to advance our knowledge and practice. 2) Accept that mental health is a children’s health issue. The 1 in 5 children in the United States who suffer from a mental illness encompasses a wide range of diagnoses. Of the 15 million children affected by such conditions, only 20% ever receive treatment. This is especially sobering when we consider that, by age 14 years, half of all lifetime diagnoses of mental illness will begin manifesting, and that 75% will show up by age 24. In the face of these numbers, children and families urgently need better ways to get the necessary support.7 3) Treat the child, not the diagnosis. A diagnosis is, at best, a start, not an end. This is especially true in mental health. Children with the same diagnosis can exhibit profoundly different behaviors and can need very different approaches. To be effective, the treatment of mental health in children must be individualized for the child and his or her family, and it must include an understanding of environmental, social, and developmental factors. We should not be satisfied merely with treating symptoms in patients with mental illness, but also with improving their overall well-being. There are many studies that have shown that positive traits such as optimism and social engagement are associated with a significant decrease in mortality, and I think that, as child and adolescent psychiatrists, we
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suggests to us that these may not be distinct diseases, as we have thought for so long.”8
are in a good position to incorporate these into psychotherapy and psychosocial interventions. 4) Start screening early and ensure access to care. Even with the most advanced approaches, real change cannot be achieved if the significant shortages in pediatric mental health providers are not addressed. This is a profound failing in a health care system that is supposed to ensure that children receive the best available care. We need to continue to advocate for appropriate funding for child mental health specialists, including loan repayment, and urge lawmakers in Congress to re-enact the bill that was first introduced in the Budget Act of 1997. 5) Do school mental health right. Although the gaps in children’s mental healthcare are huge, there is also reason for hope. President Obama’s proposals following the tragedy in Newtown include significant expansion of school-based mental health services. Done right, this could be a significant benefit and could also lead to improving educational outcomes. Funds for school-based mental health were introduced in HR bill 751 in the 112th Congress, and we collectively need to advocate for such appropriations moving forward. 6) Advocate for and invest in our future research efforts. Technological breakthroughs during the past few years have helped us to understand, identify, and intervene in many medical issues before they manifest symptoms. Any discussion of the biological basis of psychiatric disorders must include genetics. Indeed, we are beginning to fit new pieces into the puzzle of how genetic mutations influence brain development. The largest genome-wide study of its kind from the multinational CrossDisorder Group of the Psychiatric Genomics Consortium (PGC), published earlier this year in Nature Genetics, revealed the extent of genetic overlap among 5 major psychiatric disorders—a potential boon for research and eventually treatment. To quote Patrick Sullivan and co–senior author Kenneth Kendler, “It allows us an unprecedented look ’under the hood’ at what the genetic data tell us about these 5 important psychiatric disorders. The clear overlap in genetic risk for these disorders
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In 2009, the National Institute of Mental Health (NIMH) launched the Research Domain Criteria (RDoC) project, which is developing a mental disorders classification system for research, based more on underlying causes than on symptoms. It is hoped that the RDoC project will go beyond our current disorder classification system to look at the behavior systems and fundamental brain circuits that cut across many disorders.9 A recent study of adults with depression treated with either cognitive behavioral therapy or an antidepressant medication found that persons who started with below-average baseline activity in the right anterior insula responded well to cognitive behavioral therapy, but not to the antidepressant and vice versa.10 This opens the possibility for personalized treatment with the potential that one could predict a depressed person’s response to specific treatments from the baseline activity in the right anterior insula. These results lead us to believe that neural circuits disturbed by psychiatric disorders are likely to be very complex, and that psychotherapy is a biological treatment that can produce lasting, detectable physical changes in our brain, much as learning does, and that the effects of psychotherapy can be studied empirically. These are all exciting, cutting-edge, and innovative ideas, and the future of our field in many ways lies in the discoveries and treatments that are yet to come. The research that occasions these developments may not just enhance our ability to make diagnoses, but may fundamentally redefine the nosology of mental disorders. The history of medicine is punctuated by certain inflection points that mark transformative changes. We are certainly approaching another such moment in our profession’s development, and it is just around the corner: the Affordable Care Act—both a boon for our field and an opportunity that we cannot and must not pass up. I cannot help but reminisce about the time when we faced another wind of force, “Managed Care,” and the impact that it had and continues to have on our field and how we practice today. Mental health care has been greatly enhanced by the passage of the Patient Protection and Affordable Care Act (ACA), which includes mental health within its changes to health care. This hard-fought piece of legislation might end up being a game changer for
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mental health. The inclusion of mental health will lead to profound changes that will play out over the next generation. However, any assessment of the state of America’s mental health system must begin with a realization that we have begun to take big steps away from an approach that was both separate and unequal. The major challenges facing us are, first, whether including mental health in health care can be done sensibly, and second, whether the portions of the mental health safety net that have value can be sustained. Inclusion creates great opportunities that we can seize or let slip away. How do we accomplish this? A first major challenge for the next decade is to integrate basic mental health care into primary care, which could be a core element of getting mental health parity right. It can be done well, improving health and reducing costs, but barriers must be addressed. We know that most children are treated by their pediatricians or other primary care practitioners rather than by child and adolescent psychiatrists. Improving basic mental health care in primary care is a huge need and opportunity, and a responsibility that we need to embrace and take the lead on; for if we do not, someone else will. I am delighted that some of our own members have already spearheaded successful model programs in a number of states around the country. At the same time we also need to ensure cross-disciplinary assessment for children, which includes pediatrics, psychology/psychiatry, social work, physical medicine and rehabilitation, neuropsychology, and neurology. Furthermore, standardization and integration of mental healthcare such as electronic medical records and integrated databases will be important. A recent monograph published by the Institute of Medicine, Preventing Mental, Emotional, and Behavioral Disorders among Young People: Progress and Possibilities, highlights prevention in psychiatry—in childhood and across the lifespan.11 The future can and should be brighter for our patients and their families. Lastly, I want to share the elements of my Presidential Initiative. The goal of each President is to leave the Academy with a contribution that will serve well the field, its members, and ultimately our patients and their families, and thereby leave the Academy a better organization. Given the fact that there is such a dearth of child and adolescent psychiatrists in the world, it is imperative that we at AACAP share what we
have in the way of goodwill, resources, and our many materials with our colleagues around the world. Although we celebrate and pride ourselves on the unique aspects of each culture and country that define and separate us, there is much more that unites us. The mental well-being of all children and adolescents around the world is a common goal that we share. As has been said, “To whom much is given, much is expected,” so I also feel this to be a moral imperative that we at AACAP have an obligation to embrace our colleagues globally, and to learn from and share with each other. We at AACAP can benefit so much from other international organizations and their members. This collaboration can only add to the richness of AACAP and its mission and members. The Academy has grown so much over the past 60 years and now has a strong global influence that extends beyond our shores to other nations. Our Academy is quite diverse in its membership, but we can and should appeal to an even broader group of colleagues with opportunities for everybody, especially our younger colleagues who are the future of our field. With this in mind, I decided to title my presidential initiative, “Partnering for the World’s Children.” Perhaps it is my background and earlier life experiences both personally and professionally that have attracted me to the global aspect of child and adolescent psychiatry (CAP). In the end, it is our personal experiences that shape us and define who we are as individuals. I feel so fortunate to have colleagues such as Joaquin Fuentes, YoungShin Kim, Howard Lui, Bennett Leventhal, and Norbert Skokauskas on the Steering Committee, whose role it is to be a sounding board, to advise me, and to review the recommendations that will be made by the various AACAP committees that have been tasked by me to look at 4 major areas: membership structure, educational materials, the AACAP website, and international relations. I hope that the fruits of this initiative will lead to enhancing AACAP’s relationship with international organizations, collaborations, and sharing of educational resources, making AACAP’s website more accessible to international colleagues, providing support for international medical graduates, and examining AACAP’s membership categories. I would like to use existing relationships between AACAP and other child psychiatry organizations to facilitate opportunities for our members and to foster the
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global work of the organizations. No single organization can do it all, and each has its own resources, programs, and meetings; and it would be wonderful if we could support each other, share, and promote our various efforts. In conclusion I would like to say that, although some of the issues that I have raised do not necessarily suggest “easy fixes,” mental health concerns are coming out of the shadows at a time of major change in health care, and we need to seize all opportunities to improve health care for millions of children. Sometimes it is very hard to remind the public—and even ourselves—that we are living in a moment of unprecedented scientific progress and with an array of therapeutic interventions with extraordinary effectiveness. It is easy to lose sight of these positive aspects of our discipline, but we find ourselves at the right moment in time, have the scientific momentum, public health imperative, and moral
imperative—and there is nothing to be defensive or shy about. I am very optimistic that together we can all work to advance our field, preserve our identity, and provide the best care that we can to our patients. To do this, we must be able to collaborate, be intellectually and politically active, remain well organized, and share common goals and agendas, so we can speak with one voice on the world stage. & Dr. Joshi is with Children’s National Medical Center and is president of the American Academy of Child and Adolescent Psychiatry, 2013e2015. A version of this Presidential Address was delivered on October 23, 2013, at the 60th Annual Meeting of the American Academy of Child and Adolescent Psychiatry in Orlando, Florida. Disclosure: Dr. Joshi is a Psychiatry Director of the American Board of Psychiatry and Neurology (ABPN). 0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2013.10.009
REFERENCES 1. Snodgrass J. William Healey (1869–1963): Pioneer child psychiatrist and criminologist. J Hist Behav Sci. 1984;20:332-339. 2. Healey W. The Individual Delinquent: A Textbook of Diagnosis and Prognosis for All Concerned Understanding Offenders. Boston: Little, Brown; 1959. 3. AACAP Mission Statement [adopted by Council October 29, 1994; amended and approved by Council June 27, 2010]. Available at: http://www.aacap.org/aacap/About_Us/Mission_Statement.aspx. Accessed November 20, 2013. 4. Joshi P. Mental health services for children and adolescents: Challenges and Opportunities [editorial]; JAMA Psychiatry. (in press). 5. Olfson M, Blanco C, Wang S, Laje G, Correll C. National trends in mental health care of children, adolescents and adults by officebased physicians. JAMA Psychiatry. (in press). 6. Frank RG, Glied SA. Better But Not Well: Mental Health Policy in the US Since 1950. Baltimore, MD: Johns Hopkins University Press; 2006.
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7. Centers for Disease Control and Prevention. Mental health surveillance among children—United States, 2005–2011. Morbid Mortal Wkly Rep. 2013;62 (Suppl):1-35. 8. Sullivan P, Kendler K. Cross Disorder Group of the Psychiatric Genomic Consortium: genetic relationship between 5 psychiatric disorders estimated from genome-wide SNP’s. Nature Genet. 2013;45:984-994. 9. Insel T, Cuthbert B, Garvey M, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010;167:748-751. 10. McGrath CL, Kelley ME, Holtzheimer PE, et al. A neuroimaging treatment selection biomarker for major depressive disorder. JAMA Psychiatry. 2013;70:821-829. 11. Institute of Medicine of the National Academies. Preventing mental, emotional, and behavioral disorders among young people— progress and possibilities: Institute of Medicine of the National Academies. Consensus Report March 12, 2009. Washington DC: National Academies Press;2009.
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