Bringing children's mental health “out of the shadows”

In May 2006, the Honourable Michael Kirby, chair, and the Honourable Wilbert Keon, deputy chair of the Standing Senate Committee on Social Affairs, Science and Technology, issued their final report on mental health: Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addictions Services in Canada.¹ Advocacy groups and professional associations across the country applaud the profile that this report gives to mental health. Yet the inherent focus on the recovery of adults with serious mental illness may be disappointing to those concerned with children's mental health.

Mental health is fundamental to children's social and emotional development, and therefore to well-being and function throughout their entire lifespan. However, an estimated 14% of children (or 800 000) in Canada experience mental disorders that cause clinically significant symptoms and impaired functioning.² Anxiety, behavioural and depressive disorders are the most common mental disorders among children.³ Mental disorders frequently persist into adulthood and cause lifelong distress and disability.⁴ Given the associated human and fiscal costs, mental disorders are a leading health concern in Canadian children after infancy.

Although the Kirby–Keon report devotes a chapter to children, only 10 of its 118 recommendations explicitly focus on young people — predominantly those with an existing mental disorder. Recommendations to improve mental health services to children and to move services into nonstigmatizing settings are irrefutably important, but in emphasis, decidedly “downstream”: that is, they go into effect after problems are already entrenched. Recommendations that look “upstream” to where problems begin — that is, to promote social and emotional well-being and to prevent mental disorders early in life — are largely absent.

Out of the Shadows may reflect the predominant Canadian health policy emphasis. Nationally, health care expenditures comprise an estimated 95% of total health expenditures, with health care spending now totalling over $140 billion annually and with 44% of this spending being directed toward Canadians over the age of 65 years.⁵ In keeping with this emphasis, investments in children's mental health traditionally have gone largely toward specialized treatment services — yet, an estimated 75% of children with mental disorders do not access such services.² Although many children do receive interventions in other settings such as primary care and schools, the capacity of these services to deliver effective treatments (such as cognitive–behavioural therapy) is limited.² Given the limited reach of treatment services, continuing to invest mainly in treatment will likely have minimal impact on mental health of the population,⁶ in keeping with our increasing understanding that expansion of health care does not necessarily produce health.⁷

Mounting research evidence suggests that childhood is the optimal time to influence determinants of social and emotional well-being.⁸ Recent research also demonstrates that prevention programs in childhood can reduce the prevalence of mental disorders, while also addressing causal factors.⁹ For example, targeted parent training within disadvantaged families can significantly reduce subsequent prevalence of behavioural disorders in children, while also improving educational and social outcomes.⁹ In light of the research evidence and our increasing recognition of the importance of evidence-based policy-making, a public health strategy is needed, not only to provide effective treatment for children with established disorders, but also to promote the social and emotional well-being of all children, and to prevent mental disorders wherever possible.⁸

In their report, Senators Kirby and Keon proposed new transition funding to develop a community mental health system. Although children's needs are acknowledged, the principal funding components suggested, for adequate housing and a basket of community services, are again most germane to adults living with serious mental illness. The risk is that children's mental health — never prominent on the Canadian health-policy agenda and termed the “orphans' orphan” of health and health care by Senator Kirby himself — will be eclipsed by the immense needs in the realm of adult mental health.

The absence of a broader child-focused strategy may reflect a recognition that such a strategy is less appropriate for adults (given that many mental disorders begin in childhood)^3,4 and conforms to the relative rarity of programs to promote mental health or prevent mental disorders for children in Canada.⁹ One exception is found in British Columbia, where the provincial government's 2003 Child and Youth Mental Health Plan¹⁰ has shifted policy investments “upstream.” BC's Ministry of Children and Family Development is implementing this plan with new investments totalling $46 million over 5 years. Four major goals are being pursued: reducing risk, building community capacity, improving treatment and support, and monitoring performance. As part of risk-reduction efforts, new prevention programs have been introduced. Most notable is FRIENDS, a universal program for the prevention of anxiety and depression, now being implemented in elementary schools across the province. Originally developed in Australia, this program equips teachers to deliver a brief curriculum based on principles of cognitive–behavioural therapy to enhance coping and reduce disorder prevalence among children.⁹ Since FRIENDS was introduced in 2004, it has been implemented in 45 of BC's 60 school districts, with over 47 000 children in grades 4 and 5 participating. The program's effectiveness is now under evaluation.

In BC, 15% of resources committed through the Child and Youth Mental Health Plan are targeted for disorder prevention and other risk-reduction initiatives. This is notable, given that BC, like other Canadian jurisdictions, typically devotes only 5% of overall health spending to public health, including prevention activities.⁵ BC's prevention investments exemplify a new and deliberate shift from exclusively focusing “downstream” on treatment services toward a broader public-health strategy to reach greater numbers of people early in life.

Mental health begins in childhood. If we are to make a difference to the health of the population, new investments to ensure optimal social and emotional development in children and to prevent mental disorders should be much more prominent within any national agenda to transform the mental health system. Without question, adults with serious mental illness require a renewed mental health system. But the broader goal should be to improve the mental health of all Canadians. We cannot achieve this goal if we do not bring children's mental health “out of the shadows” as well. Investments in children's mental health are surely among the most important investments that any society can make.