If you’re ready for a crash course in mental health, read Alison Cuellar’s article in the new volume of Future of Children “Policies to Promote Child Health.” She introduces us to internalizing and externalizing conditions that children experience, as well as the trajectories and outcomes that can accompany them. She also describes prevention programs, and interventions from academic, juvenile justice, and medical and social service angles.
Unfortunately, well intended programs and interventions often come with an unintended consequence. Cuellar argues that due, in part, to differing funding structures of schools, health care providers, and juvenile justice programs, there is an inherent lack of integration among treatment providers; thus, children sometimes fall through the cracks. For example, health insurance might not pay for anything beyond direct professional services provided to a child; whereas parent education or family treatment might be necessary but not be covered. Another example would be programs funded by the Substance Abuse and Mental Health Services Administration—while there might be more flexible funding available for intervention and prevention initiatives through this funder than health insurance, funding is limited to particular communities and settings; thus excluding children not found in these areas.
I’ll be frank in saying that there isn’t an easy method to defragment a complicated system of service delivery. Cuellar concludes that we need to identify ways to overcome fragmentation between services. Volume editors Currie and Reichman call on governments to follow the lead of businesses and make use of the vast amount of data available to them to “create an integrated portrait of child health or to target policies to those who have the most to gain from them.”
In a blog post last year, I wrote about how the Affordable Care Act was a step in the right direction to allow for a more integrated health care system and that there were existing initiatives, such as the patient-centered medical home model, that encourage coordination among providers. Perhaps future policies and practices will encourage coordination among mental health services, thereby improving child mental health.
Education tends to pay off. Higher educational attainment is associated with higher earnings, lower unemployment and better health. In the Future of Children, Neeraj Kaushal explains that education also influences important lifestyle decisions such as marriage, sex, childbearing, and substance use.
Importantly, parents’ education not only affects themselves, but also affects the wellbeing of their children. Better-educated parents often pass down the tradition of education to their children along with its benefits. The intergenerational payoffs of education are persistent and perhaps even underestimated.
While some families benefit immensely from education, other families face structural obstacles to advancing their socioeconomic status via further educational attainment. Racial and ethnic disparities are apparent by education, and children with less-educated parents are less likely to succeed in school. Furthermore, Kaushal points out, the U.S. education system reinforces socioeconomic inequality across generations by spending more money on educating richer children than poorer children.
These challenges lend support to the idea of targeting education-related interventions toward less-educated parents and their children. This might be done via a two-generation approach in which parents and children are served simultaneously. While the theoretical basis for these programs is strong, the empirical evidence is only emerging. What we do know is that investing in parents is likely to have a lasting effect on children’s health and development, which in turn increases their wellbeing as adults. There is also evidence that adult offspring’s educational attainment influences the health and life expectancy of the parents, even after accounting for parents’ socioeconomic resources. This may be due to children’s knowledge of health and technology they share with their parents and having more financial means to support them. It’s arguable that investing in programs that aim to increase parents’ education and skills at the same time as they invest in children’s development could go a long way to reduce intergenerational inequality.
For more information about two-generation programs, see the Future of Children volume Helping Parents, Helping Children: Two-Generation Mechanisms.
Evidence linking alcohol and other drug abuse with child maltreatment, particularly neglect, is strong. But does substance abuse cause maltreatment? In a recent article in The Future of Children volume Preventing Child Maltreatment, authors Mark Testa and Brenda Smith found that co-occurring risk factors such as parental depression, social isolation, homelessness, or domestic violence may be more directly responsible than substance abuse itself for maltreatment. Interventions to prevent substance abuse–related maltreatment, say the authors, must attend to the underlying direct causes of both.
Research on whether prevention programs reduce drug abuse or help parents control substance use and improve their parenting has had mixed results, at best. The evidence raises questions generally about the effectiveness of substance abuse services in preventing child maltreatment. Such services, for example, raise only marginally the rates at which parents are reunified with children who have been placed in foster care. The primary reason for the mixed findings is that almost all the parents face not only substance abuse problems but the co-occurring issues as well. To prevent recurring maltreatment and promote reunification, programs must ensure client progress in all problem areas.
At some point in the intervention process, attention must turn to the child’s permanency needs and well-being. The best evidence to date suggests that substance-abusing parents pose no greater risk to their children than do parents of other children taken into child protective custody. It may be sensible to set a six-month timetable for parents to engage in treatment and allow twelve to eighteen months for them to show sufficient progress in all identified problem areas. After that, permanency plans should be expedited to place the child with a relative caregiver or in an adoptive home.
Investing in parental recovery from substance abuse and dependence should not substitute for a comprehensive approach that addresses the multiple social and economic risks to child well-being beyond the harms associated with parental substance abuse.