As a prevention-focused, public health psychiatrist, I am committed to proactively addressing the needs of patients with mental health problems. In light of this commitment, I want to bring to your attention several recent advances in prevention in psychiatry.
When Dr. David Satcher served as the 16th surgeon general, during his 2000 Conference on Children’s Mental Health, he suggested three areas of focus for mental health professionals that would lead to improving the public’s health: protective services, special education, and juvenile justice. Taking his advice, many of us have been working in these areas and gaining some ground.
Dr. Carl C. Bell
Child Protective Services
More than a decade ago, some disturbing trends became apparent in downstate Illinois in McLean County. Although the statewide average of removing children from their families was 4/1,000, child protective services in that county were removing 40/1,000 children from their families.
The director of the Department of Children and Family Services (DCFS) learned about this problem and sent Community Mental Health Council (CMHC), and Urban Services, downstate to fix this problem. CMHC is a mental health center that uses evidence-based practices to serve its community in Chicago, and Urban Services is a social service agency that seeks to support communities by improving their social cohesion and control. By using a seven-field principle model that strengthened families, we were able to reduce the number of children being removed dropped from 24.1/1,000 down to 11.1/1,000.
Furthermore, follow-up studies indicated children and families in the intervention were far less likely to have subsequent hotline calls, compared with those not in the intervention. Thanks to the leadership of several subsequent DCFS directors, slowly but surely, Illinois began to infuse intact family services into their agency.
The result was Illinois was able to reduce the number of children being removed from their homes from 4/1,000 down to 1.8/1,000. Fortunately, for the nation, President Barack Obama appointed Bryan Samuels, a former DCFS directors who infused a prevention into Illinois DCFS, as the commissioner of the Administration of Children, Youth, and Families, and he is on a mission to spread what he started in Illinois to the entire nation.
Youth in Special Education
Earlier this year, I realized that fetal alcohol syndrome (FAS) was a serious contributor to the four major and common problems children have (speech and language disorders, attention-deficit/hyperactivity disorder, specific learning disorders, and mild mental retardation).
It is interesting to me how focused psychiatry is on neuropsychiatry and brain imaging, but as far as I know, there is no objective test available to diagnose FAS other than the characteristic facies with which a child with serious FAS is born but gradually outgrows, making it difficult to diagnose an adolescent or adult.
Someone once suggested that if I suspected any of the four major and common problems of children, I ask to see a baby picture to see whether I can recognize the characteristic facies of FAS. While I am more a fan of clinical medicine/psychiatry than I am of laboratory medicine/psychiatry, I wonder why our neuropsychiatric researchers have not tackled this common problem.
Regardless, the problem of FAS does seem to be on federal radar as a potentially major prevention initiative, and the Substance Abuse and Mental Health Administration is certainly aware of the problem as the agency cites fetal alcohol spectrum disorders as more common than autism. Fortunately, some states are ahead of the curve (for example, Alaska and Washington states), and there is a National Organization on Fetal Alcohol Syndrome (NOFAS). Hopefully, the observations about the huge impact that FAS makes on special education will pan out, and we will see some prevention traction in the area of special education – as we did with cretinism and phenylketonuria.
Youth in Juvenile Justice
For me, providing treatment to young people who have wound up in the juvenile justice system has been the toughest challenge, because the psychiatrist’s ability to influence such systems is minimal. However, a recent National Academy of Sciences (NAS) report – "Reforming Juvenile Justice: A Developmental Approach" – has just been released, and, if this report gains footing in the United States, we will all be much better off.
As director of the Institute for Juvenile Research (IJR) – where child psychiatry started – I am familiar with the development of the first juvenile court in the United States. It was shortly thereafter that the same group of women (led by Nobel Prize–winning social workers Jane Addams and Julia Lathrop) who developed that special court began IJR to study delinquency. It turns out more than 100 years later, we are rediscovering their wisdom as the new NAS report illustrates.