California Mental Health Advocates for Children and Youth Conference

1
(No Transcript)
2
California Mental Health Advocates for Children
and Youth Conference
Overcoming Disparities in Childrens Mental
Health Challenges and Opportunities for
Californias Mental Health Systems
Sergio A. Aguilar-Gaxiola, MD, PhD Center for
Reducing Health Disparities UC Davis School of
Medicine Asilomar, CA May 17, 2007
3
Acknowledgements

• Larke Nahme Huang, PhD
• Karen A. Blaisé, PhD
• Dean L. Fixsen, PhD
• Jane Knitzer, PhD

4
Why Disparities Matter?

• Increasing growth rate and percentage of
  racial/ethnic minorities in the U.S. and
  California population.
• Poorer health status and health care outcomes of
  some racial/ethnic minority populations have been
  well documented.
• Some of the factors contributing to the poor
  health status and poor health care outcomes of
  racial/ethnic minorities are not well understood.

5
Why Should Disparities Matter?

• Disparities challenge our societys core values
  of justice, fairness, and equity.
• Disparities are incompatible with quality of
  care.
• Disparities are bad public health policy
  Resources are often misallocated to those who
  derive the least benefit.

6
Selected Findings A Public Health Crisis in
Mental Health

• 20 adults/children have a mental health problem
  in the past year
• 1 in 10 youth has a serious emotional disorder
• 9 of adolescents, age 12-17, experienced at
  least one major depressive episode in the past
  year (2004) Those who experience a MDE were more
  than twice as likely to have used illicit drugs
  (2004).

Source Huang, 2004
7
Selected Findings A Public Health Crisis in
Mental Health

• Youth Suicide 30,000 a year (80/day)
• 40 had contact with primary care provider
  within the last month
• Adolescents 15-18y/o 3rd leading cause of
  death 11 suicides each day 17-19 think about
  killing themselves 5-8 make attempt only 1/3
  get treatment among Latino girls, 1 in 5 make
  suicide attempts states spend over 1 billion on
  medical costs associated with suicides and
  suicide attempts by youth under age 20.
• Only half of individuals with serious mental
  illness get treatment, services or supports
  access to care is worse for ethnic minorities

Source Huang, 2004
8
Selected Findings for Children

• Of children with serious emotional/behavioral
  disorders 50 drop-out of high school (compared
  to 30 of students with other disabilities)
• Youth entering Juvenile Justice 66-75 have
  serious emotional problems (Coalition on Juvenile
  Justice Teplin)
• 1/3 children in mental health system have a
  co-occurring disorder (age 11 age 17-18 SA)

Source Huang, 2004
9
Selected Findings for Children

• 500,000 children in foster care estimates up to
  40-80 have emotional/ behavioral and/or
  substance abuse problem
• 44 lt 5 yrs old
• highest of lt 1yr olds are Latino
• of Latino youth in foster care, 57 lt 5yrs old

Source The AFCARS Report  Preliminary FY 2001
Estimates as of March 2003.  Washington, D.C.,
DHHS, 2003.  ( latest federal statistics  on
foster care supplied by the states for the
Adoption and Foster Care Analysis and Reporting
System Zero to Three)
10
Disparities for Children of Diverse Racial and
Ethnic Groups

• African American and Latino youth
  identified/referred at same rates as general
  population, but less likely to receive specialty
  mental health care or medications (Kelleher,
  2000)
• African American and Latino children have highest
  rates of unmet need (Sturm, 2000)
• Asian American and Latino female teens have
  highest rates of depression (The Commonwealth
  Fund, 1997)

11
Disparities for Children of Diverse Racial and
Ethnic Groups

• Minority children tend to receive mental health
  services through juvenile justice and child
  welfare systems more often than through schools
  or mental health setting (Alegria, 2000)
• In child welfare, minority youth have poorer
  outcomes, fewer services, less likely to have
  plans for family contact and more likely to be in
  out-of-home placements (Courtney et al, 1996).

12
Rural Disparities

• Rates of mental disorders are similar between
  rural and urban youth, although limited sampling
  in rural America
• Exception Rural adolescents have higher rate of
  suicide than urban counterparts
• Significantly higher rate among Native American
  youth
• Child poverty higher in rural areas children of
  color at-risk with 46 African American, 43
  Native American and 41 Latino rural children in
  poverty

13
Outcomes Start Poor

• Young children with challenging behavior/social
  and emotional problems
• Experience greater rates of early school failure
  
• Poor relationships with teachers
• Academic learning skills unrecognized
• Typically STILL do not get appropriate help until
  4th grade (Knitzer, 1982, 1992)

Source Knitzer, 2006
14
Outcomes Stay Poor

• In high school, students with Severe Emotional
  Disorders are least likely to
• Get As Bs (28)
• Adjust well socially (41 Low social skills)
• STAY IN SCHOOL (72 suspended or expelled)
• Avoid juvenile justice (over one-third arrested)

Source Wagner, Marder et al. 2003 Wagner,
Newman, et al., 2003 Knitzer, 2006 Knitzer,
2006
15
Unmet Need What is Wrong with this Picture?

• 1982 Unclaimed Children estimated that less than
  20 of children in need of services got them
  (Knitzer)
• 2002 Fewer than 21 of children in need of
  mental health services received them (Kataoka)
• In 20 years, 1 increase?

Source Knitzer, 2006
16
(No Transcript)
17
What is the Current Status of Mental Health
Services of Children and Youth?
18
The Unmet Need is Greater by

• AGE Young children (17 have diagnosable
  disorders, 1-2 identified 10 problem
  behaviors 3 times as much in low-income
  communities).
• RACE/ETHNICITY Prevalence rates are similar, BUT
  children of color less likely to access care and
  STILL overrepresented in emergency settings
  (i.e., African American and Latino children are
  still more likely than Whites to end up in the
  most intensive care settings, to underutilize
  certain services, and to achieve poor outcomes).

Source Knitzer, 2006 Hsia, Bridge, McHale,
2004
19
The Unmet Need is Greater by

• SETTING
• Child welfare ( 50 need,15 served for young
  children, 1/3 need, 7 served Burns, 2004)
• Juvenile Justice (65-70 prevalence)
• Schools (44 of EBD served thru schools Bradley
  et al., 2004)
• PLACE rural areas particularly underserved

Source Knitzer, 2006
20
Challenges Impacting Prevention and Early
Intervention Efforts

• Demographic trends
• Mental illness prevalence and onset
• Service access and utilization
• Disparities in care
• Avoiding doing business as usual truly
  transforming the mental health system.

21
Californias Population, 1990-2000
Source US Census Bureau, California Department
of Finance
22
Californias Population by Race and
Ethnicity

• California leads the nation in diversity.
• As such, the state is challenged with a
  substantial leadership role in designing and
  maintaining services that achieve cultural and
  linguistic competency.

Source Johnson, Californias Demographic Future,
Public Policy Institute of California, 2003
23
Source of Growth has ChangedAnnual Population
Change 1950-2003 (in thousands)
24
Births in California 1950-2000
In thousands
25
(No Transcript)
26
(No Transcript)
27
Source The Annie E. Casey Foundation
28
Unique Challenges in Some Areas in California

• High poverty
• High unemployment
• High uninsurance or underinsurance rates
• High school drop-out rates
• Rural, dispersed communities
• Highly ethnically, culturally and linguistically
  diverse communities
• Intercultural, intergenerational stress.
• Yet, with
• Creative leadership, compelling commitment, new
  resources
• Present a Unique Opportunity for Discovery,
  Leading Innovation, and Transforming Existing
  Practice

29
How can we transform services and supports to
prevent high risk behaviors and improve outcomes
in children and youth?
30
Letter to Stakeholders DMH Director Steve Mayberg

• To expend funds made available through this
  initiative to transform the current mental health
  system in California This will not be business
  as usual. Eventually access will be easier,
  services more effective and out-of-home and
  institutional care will be reduced.

31
To transform childrens mental health, we must

• Send a message of hope for systems as well as for
  children and families
• If we provide a service the community wants, and
  it is funded, transformation will occur

32
Principles Underlying Transformation

• Services and treatments that
• Are consumer and family-driven, not focused
  primarily on the demands of bureaucracies
• Provide real and meaningful choice of treatments,
  services and supports and providers

33
Principles Underlying Transformation

• Care is geared to
• Promoting consumers and familys ability to
  manage lifes challenges successfully
• Facilitating recovery
• Building resilience, not just managing symptoms

34
Principles Underlying Transformation

• Services and Supports that are based on
• Rebalancing of Services and Financing
• Effective Solutions for Reducing Disparities
• Using What Works
• Technology in Service to Quality Care
• In Addition, Prevention, Early Identification and
  Intervention Efforts

35
A Framework Toward Positive Outcomes for ALL
Youth

• Public spending should be consistent with the
  best science
• Identify the issues and build on the strengths
• Bring diverse partners to the table
• Engage in shared, strategic planning involving
  schools and communities
• Identify interventions that are culturally and
  linguistically effective and implementation
  strategies
• Evaluate the effort and use the data to
  continuously improve the strategies
• Invest in prevention and early intervention in
  addition to mental health services.

36
No mass disorder afflicting humankind has been
eliminated or brought under control by attempts
at treating the affected individual, nor by
training large numbers of individual
practitioners
George Albee,Past President, American
Psychologist Association
37
The Role of Prevention in Eliminating Health
Disparities

• Health care is not the primary determinant of
  health
• Improving health access is only part of the
  solution to improving health outcomes and
  reducing health disparities
• There are three reasons why improving access to
  health care alone will not eliminate disparities
• Clinical care treats one person at a time
• Intervention often comes late
• Clinical care is usually sought after people are
  sick (fail first).

Source Mikkelsen, Cohen, Bhattacharyya,
Valenzuela, Davis, Gantz,2002.
38
The Role of Prevention in Eliminating Health
Disparities

• Prevention and Early Intervention can make a
  vital contribution to current efforts to reduce
  disparities in health.
• By addressing the underlying factors that
  negatively influence health, prevention has the
  power to reduce the incidence of poor mental
  health and disability and premature death.

Source Mikkelsen, Cohen, Bhattacharyya,
Valenzuela, Davis, Gantz,2002.
39
Understand that.we need to simplify the message

• Communities, legislatures, governors will not
  always understand why systems of care, or
  evidence-based practices, or recovery and
  resiliency or childrens self-esteem are good
  things.
• They will understand why children and youth who
  do not kill themselves, who are not incarcerated,
  who do not drive drunk, who remain with their own
  families and are not homeless, who graduate, who
  have higher incomes as adults, and who contribute
  to the community is a good thing.

40
MHSA and Disparities

• Reduction of disparities in mental health and
  access to mental health care was a central goal
  of MHSA.
• How do we do it?
• What are the problems that underserved
  communities experience and report?
• How can mental health services better address the
  needs of historically underserved communities?

41
Where are the disparities?

• groups historically underserved by mental health
  services, as evidenced by county, state and
  national-level data
• groups facing particular barriers to
  participation in the policy process, such as
  geographic or linguistic isolation
• groups identified as mental health priority
  populations
• groups with high levels of uninsurance,
  underinsurance and/or poverty.

42
Key Elements in Addressing and Reducing
Disparities

• A Planning Process
• Data Utilization and Quality Improvement
• Adaptations of Services and Supports to Address
  the Needs of Underserved Communities
• Infrastructure Building
• Targeted Training and Technical Assistance
• Infrastructure-building
• Powerfully Framed Messages and Communications
  Strategy
• Champions, Allies and Coalition Building.

Source Huang, 2007
43
3. Restructuring the Array of Services and
Supports

• Key Themes
• Community Based Partnerships
• Outreach and Engagement
• Interface of Primary and Behavioral Health Care
  and Co-location
• Adaptations and Practice-based Evidence

Source Huang, 2007
44

• Go in search of people. Begin with what they
  know. Build on what they have
• Chinese proverb

45
Learning How to Reduce Disparities

• We need direct input from underserved
  communities.
• Not an easy task. Underserved communities may be
  
• Unaware of potential benefits.
• Not ready to participate in policy process.
• Suspicious and distrustful of mental health
  services.

46
Collaborating with Underserved Communities
Addressing Prevention and Early Intervention
Needs Through Community Participation

• DMH contract with the
• Center for Reducing Health Disparities
• UC Davis School of Medicine

47
Overall Goal

• To develop a process for community engagement in
  historically underserved and isolated
  communities, to solicit their input and encourage
  ongoing, meaningful input and participation in
  the planning, implementation and evaluation of
  prevention and early intervention efforts.

48
Specific Goals

• Do outreach to communities that have been
  historically underserved by public mental health
  services and not included in previous community
  stakeholder processes.
• Develop a community engagement process to ensure
  direct input from underserved communities based
  on
• Respect and mutual trust
• Investment in community relationships
• Collaborative action aimed at soliciting input
  regarding communities needs, perspectives,
  strengths, and assets.

49
Specific Goals

• Solicit and gather input regarding Prevention and
  Early Intervention programs, priorities, and
  strategies.

50
Principles of Community Engagement

• Community engagement processes are about personal
  and local relationships that should be
• Participatory
• Cooperative
• Conducive to learning from each other
• Encourage community development and capacity
  building
• Empowering
• IDENTIFY also ASSETS, STRENGTHS, RESOURCES within
  COMMUNITIES

51
Outreach Process

• Identify specific underserved communities
• Interview key informants to focus on specific
  needs within communities
• Work with cultural brokers or community health
  representatives to develop culturally and
  linguistically sensitive outreach strategies
• Conduct focus groups with community members about
  mental health needs, community assets, etc.
• Provide feedback to communities about the impact
  of the information collected on policy and
  services.

52
Preliminary Findings Key THEMES from
Interviews and Focus Groups

• Lack of housing
• Exposure to trauma
• Poverty
• Social isolation
• Linguistic barriers
• Discrimination
• Lack of access
• Shame
• Mistrust of the system

53
Preliminary Findings

• Community Assets
• Social networks and supports (varies across
  groups)
• Community based-grassroots organizations
  providing much needed services
• Promotoras or outreach workers
• After-school activities (when available)

54
Preliminary Findings

• Mental Health Problems that should be addressed
  in PEI process
• family violence
• substance abuse
• emotional disorders in children
• parenting, parent-child interactions
• discrimination against persons with MH
• issues
• social isolation, especially of elders.

55
Wish list

• Health and mental systems must respond to current
  and projected demographic changes
• Health and mental systems must eliminate
  long-standing disparities in mental health care
  for people of diverse racial, ethnic and cultural
  backgrounds
• The mental health system must develop a diverse,
  competency-based workforce invested in improving
  quality of care and outcomes
• Evaluation of mental health programs must be
  tailored to the needs of the service users.

56
So, what?

• How is this relevant to what you do?
• How does this information guide restructuring
  services and supports and preventive and early
  intervention efforts for children, youth, and
  families?