“By all accounts,” says NYU Silver School of Social Work professor Ramesh Raghavan, “it’s really hard to be a kid in America today.”

While the past five decades have seen numerous strides in population health—deaths from smoking and driving accidents have plummeted, for example—the pattern has not been replicated in mental health outcomes for children and adolescents. In fact, Raghavan notes, a little under half of American youth say they feel persistently sad, one-third say their mental health is poor, and a fifth report seriously contemplating suicide.

Prevention and treatment have failed to reach the most vulnerable, whose conditions can worsen into adulthood if left untreated. And federal, state and local funding for programs and services is uneven and often thin. Raghavan, who worked on child mental health issues in the Obama administration in 2015 and has led several studies on the efficacy of and access to care for children in underserved communities, explains that we’re in the midst of a full-blown crisis. In a  new book, Investing in Children’s Mental Health, Raghavan and co-author  UCLA health economist Daniel Eisenberg, make the case for a boost  in government funding and new policies that support  “social vaccines,” which address the health of children’s social ecology and everyday environments. Their book provides what Iceland’s minister of education and children, Ásmundur Einar Daðason, calls a “roadmap” to investments and strategies representing “the most profitable choices that societies can make” to address child mental health.

NYU News talked with Raghavan about the underlying causes of these issues and his recommendations for a way forward.

Given that today’s kids are dealing with the recent COVID pandemic, divisive messages on social media, wars, environmental degradation, I can certainly see why you’ve depicted child mental health as one the most important problems facing the US.

It is! Kids are growing up in a very heightened state of mental vulnerability, clearly. The Surgeon General and the CDC, among others, point to a child mental health crisis, for which there are many complex causes, of course. But the mental health of young people is particularly problematic because problems are showing up at an early age, affecting developing brains in ways not fully understood, and potentially persisting into adulthood. This is why improving youth’s mental health has to be a national priority.

That would have to begin with an increase in government support, right?

While the road to improvement is not solely a function of funding, a lack of funding by local, state and the federal government is a primary reason why we don’t have the kinds of services and supports needed to improve children’s mental health consistently and widely.

Even when we do have the funding in place, we don’t always use that money to fund the best services or practices. Our book highlights several highly effective and cost-effective programs that can help, including a number of home visiting and social-emotional learning programs. Unfortunately, in many instances these proven programs only reach about 5 percent of all children at school or home who need them.

What is also concerning is that kids are receiving services in programs that do not have any basis in evidence of success. Just one example, out of many, is the Drug Abuse Resistance Education, or DARE, in which law enforcement officers visit school classrooms to talk about how to resist high-risk behaviors like using drugs. It continues to be relied upon even though it does not appear to work, according to an NIH  study among others.

There’s also a documentary playing on Netflix now, Hell Camp. It follows a program in which they take a group of kids who are acting out—at least one of them is kidnapped from her house in the middle of the night!—and send them to a boot camp in the desert in Utah. There is zero evidence that any of it works. While, to be fair, some of the most egregious programs have been shut down, a lot of non-evidence-based, so-called “treatments” persist.

In comparison, there are a number of tested school-based programs with curricula that have been shown to effectively address the risk of substance abuse and other risks facing younger adolescents. One is called Life Skills Training. Another, Family Matters, is for families in which children and teens exhibit early substance use, coupled with rebelliousness or delinquency.

 

NYU Professor Ramesh Raghavan

Professor Ramesh Raghavan (Photo by Jonathan King).

Access to treatment is a big hurdle too, but you write about how research-based, program registries can help connect mental health service agencies and schools to services.

Registries gather the best available programs on the basis of evidence, in many cases develop fact sheets on those programs for policymakers or consumers, and provide links to the underlying studies that have given rise to this evidence. We highlight about half a dozen of these compelling compendiums on behalf of decision-makers such as executive directors of mental health organizations or policymakers.

At the same time, registries have some limitations that are worth noting. They tend to elevate programs that have a great deal of research evidence, which is basically their function. But there may be many other programs out there that have not yet been fully studied, or whose level of evidence is more modest, which do not make it into many registries. They are by design a snapshot in time.

Just because a program is listed in a registry, this does not necessarily mean that a child will have the ability to access it. Availability of evidence-grounded interventions is highly variable nationwide. Registries can solve the information problem, but not the access problem.

Then, too, the quality of services can be highly uneven. How can the scientific community play a greater role here?

As academics ourselves, we recognize that there are powerful professional incentives when it comes to discovery. Most funding agencies, certainly the federal funding agencies, want to discover new interventions that can be deployed to solve novel problems. While this is certainly important from a scientific point of view, it does not seem to have benefited the mental health of America’s public. Rates of mental disorders at a population level have not shown the same precipitous declines as the incidence of stroke and heart disease over time. If Americans are not getting significantly better when it comes to their mental health, and are even getting worse, then what is it that we are purchasing through all of this federal and non-federal research spending?

What our research shows is we need to do more than merely focus on discovery. We need to fill in some of the gaps that exist in the research evidence, especially for preventative and community-based programs. We also must work on studying unproven programs that may perhaps prove to be efficacious in the future. There are clinicians who are probably getting wonderful results, but they don’t publish, so their work is a well-kept secret.

To my mind we also need to ensure that the interventions that we know are effective can be implemented easily, that we finance the costs associated with putting in place such interventions, and that we stop deploying ineffective programs.

Congress did not renew the expanded Child Tax Credit at the end of 2021, casting 10 million kids back into poverty. Are we looking at a future of “one step forward, and two steps back” with regard to the mental health of youth, especially those under the federal poverty line?

This is such a good question because it’s a key example of how we should think about children’s mental health from a much broader perspective. Mental disorders are much more than brain disorders; they’re influenced and modulated by a child’s siblings, peers, schools, families, communities, and their social and political environment.

Those of us who have been trained in public health know that the greatest advances in human health and longevity have occurred not because of advances in pharmaceuticals and other medical treatments, but due to improvements in the environments within which people live: things like expanding immunizations, providing clean drinking water, improving sanitation. Public health in many ways is the practice of medicine upon populations, albeit with a different set of tools.

Similarly, the traditional concerns of the field of social work, such as poverty, food insecurity, unstable housing, and violence, are very much risk factors for youth mental health. If a kid is traumatized because she is being abused at home, how will psychotherapy alone help solve the problem? Doesn’t it make sense for us to try and stop the abuse, which is the domain of expertise of scholars in child maltreatment and of child welfare workers?

In our book, we resuscitate the 1970s construct of “social vaccines.” These are interventions directed toward populations rather than individuals, that focus on contexts and social ecology rather than exclusively on people, and attempt to alleviate the determinants and risk factors of disease rather than the disease itself.