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The promise of the next generation: Reflections on the changing face of children’s mental health
CrossCurrents
by Dr. Marshall Korenblum

“Mary, ” a wide-eyed 14-year-old, dressed in Goth garb, was pondering my question of how she got the idea to cut herself (she had numerous scars on both arms). “Easy,” she replied. “From a chat room.”

Mary had been sharing her tales of woe with some girlfriends on MSN, and one of them had suggested she cut herself in order to feel better. On a web site devoted to self-harm, she discovered the joys and perils of cutting.

This story from my practice illustrates one of the many ways in which the face of children’s mental health has changed dramatically over the last few decades. For better and for worse, technology (the Internet in all its forms – YouTube, MySpace, Google) has revolutionized the nature of clinical practice. Parents now ask me if I have heard of such and such medication that they found through Internet research. I deal with the sequelae of cyber-bullying. Computer addiction is common, and entire relationships, including romantic ones, can be started, “consummated” and ended in a virtual world. Patients prefer to e-mail rather than phone me. This was all unheard of a scant 20 years ago.

Similarly, the level of violence and sexuality promulgated on TV and in movies and video games has increased exponentially. The impact of the media on children’s behaviour is being hotly debated, and the jury is still out. But this is clearly a very modern phenomenon.

Another way in which my practice has changed has to do with “clinical practice guidelines” and “evidence-based care.” These trends have infiltrated the field of children’s mental health. They represent an attempt to synthesize the very best of what we think “works” with kids, based on rational, scientific principles. While this is admirable, I have noticed two offshoots of these trends: First is “cookbook mental health,” in which poorly educated practitioners try to apply, in “cookie-cutter” fashion – one of my teachers once said, “If your only tool is a hammer, then everyone will become a nail” – manualized approaches to diagnosis or treatment with little appreciation for nuance, exceptions to the rule or the humanity and individuality of the families facing them. Second, we have defensive practice, as in “covering one’s behind” and trying to avoid litigation by invoking “guidelines.”

A concrete example is the scare that emerged a few years ago about SSRI anti-depressants possibly causing suicidal behaviour in young people. My consultation requests from pediatricians and family doctors skyrocketed because they were afraid to prescribe without the stamp of approval of a sub-specialist. Their fear of getting sued lengthened my waiting list astronomically.

Certainly in the last 30 years, tremendous advances have been made in diagnosis and treatment. Genetics, neuro-imaging, standardization of assessment tools and improved diagnostic criteria have furthered our understanding of disorders such as autism, pediatric bipolar disorder and schizophrenia. We are on the brink of developing markers found in blood or saliva tests for various mental illnesses. Early intervention and prevention have moved forward by leaps and bounds with the explosion of knowledge in the fields of attachment theory and infant psychiatry. Research in pediatric psychopharmacology has resulted in more effective treatment of depression, aggression and self-harm. In psychotherapy research, dialectical behaviour therapy and cognitive behavioural therapy have proven effective in treating anxiety and self-harm.

The very recent creation of a Federal Task Force on Mental Health (the offshoot of the Kirby Commission) gives reason for cautious optimism. Former senator Michael Kirby called children’s mental health “the orphan’s orphan,” referring to the sadly neglected state of affairs in our field. Whether this will result in any meaningful policy revision has yet to be seen.

Unfortunately, other changes have been much more disturbing. Children from birth to age 18 seem to have more serious and complicated problems at younger and younger ages. We are seeing earlier ages of onset for many psychiatric conditions (especially eating disorders), making them more difficult to treat. While child*hood substance abuse has declined, the types of substances are more damaging (e.g., stimulants). Cutbacks to education and health have resulted in longer waiting lists for treatments at the same time that more cases are being identified. The adverse effects of poverty and divorce have remained constant. And it seems that the prevalence of post traumatic stress disorder in children has skyrocketed, due to the effects of immigration – trying to adjust to our society and having to heal from experiences of violence and torture in other countries. Parents seem more stressed and less able to serve as the “executive functions” of their families in the way they need to be.

There has been a steady increase in the number of practitioners from all health disciplines interested in working in children’s mental health, but funding for training positions hasn’t grown correspond*ingly, so the person-power shortage will only worsen as significant numbers of practitioners retire over the next 10 years. Provincial and federal benchmarks for waiting lists have so far omitted mental health, let alone children’s mental health.

Looking to the future, lifelong learning and continuing education for workers in the field will be crucial. The knowledge explosion is upon us. The great promise is that we may make major advances in the recognition, early identification, diagnosis and treatment of mental illness in children. The challenge will be to deliver the goods – can we translate our knowledge into clinically relevant and equitably accessible help? Can we combine the best of art and science to improve the plight of young people? Or will forces outside our field, such as governmental ineptitude or societal stigma and stereotyping, conspire to perpetuate the problems of the next generation? Only time will tell.

Dr. Marshall Korenblum, FRCP(C), is psychiatrist-in-chief at the Hincks-Dellcrest Centre for Children in Toronto, and associate professor in the Department of Psychiatry at the University of Toronto.
 

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