Child and Family Policy: A Role for Child Psychiatry and Allied Disciplines

Walter S. Gilliam

Edward F. Zigler

Matia Finn-Stevenson

Child and adolescent psychiatrists, as well as their allied discipline colleagues, have long understood many of the family and societal factors that impact children’s development and functioning (e.g., poverty, community violence, substance abuse, substandard education, family discord). Many of these predictors and contributors to psychiatric impairment have been the focus of public concern, debate, and often policy development. Although child and adolescent psychiatrists and other mental health professionals have much to contribute to thinking about population-wide efforts to address these problems, few receive any training on how to understand effective policy development or their role in it.

In this chapter, we discuss some of the social changes we experience in our society, their impact on children and families, and policy responses to address these. We will also discuss the role of mental health professionals in the policy arena. It will become apparent in the course of the chapter that there are benefits as well as problems inherent in the utilization of mental health research in policy settings. A number of opportunities exist for mental health professionals to contribute to the development of policies for children and families. However, their effectiveness in this regard is dependent not only on their knowledge of scientific principles and findings from mental health research but also on their familiarity with the social policy process and their ability to work with policy makers.

What is policy

Policy is any agreed-upon set of principles used to guide decisions or procedures. Policies often are codified in written forms, such as laws, governmental regulations, or organizational procedures. In many cases, however, policies are not explicated formally and exist simply as implicit assumptions about “the way things are done.” The most formal type of policy is legislation—the laws enacted by state and federal government that create and fund service programs (public-funded prevention services, entitlement services for persons with disabilities), establish or alter rules for government services (procedures for arbitrating disputes regarding special education), and regulate the way individuals and private businesses may interact (mental health parity laws regarding insurance providers, laws regarding domestic violence and protection). Some policies are sets of governmental procedures and definitions that are developed by agency staff to guide the provision of their services, but do not rise to the formalized level of legislation. Even the rules and position statements of professional organizations, such as the American Academy of Child and Adolescent Psychiatry, are policies. What differentiates policies is the degree to which they have been formalized, who they regulate, the consequences that can be imposed for breaking them, and how difficult it is to change them. What all policies have in common is that in all cases someone first envisioned the need for a policy, someone decided what the policy should be, and some individuals or group of people actively or implicitly agreed to it. In many cases the persons writing and deciding policies understand the policy process very well, but may have little or no knowledge of the systems they are regulating or the implications of their policies.

The Need for Effective Child and Family Social Policy Development

Over recent decades, researchers and clinicians in psychiatry, developmental psychology, and other disciplines related to
mental health have become increasingly involved in the shaping of policies and legislation designed to address the mental health problems of children and youth. While the focus of legislative action on behalf of children is not new, the presence of researchers and clinicians in the debate has added a different dimension, offering new opportunities for interaction between research and policy. Mental health professionals are directing their work toward the understanding of how contemporary social problems contribute to mental dysfunction in children, not only reporting their research but also underscoring the policy implications inherent in their findings and suggesting a course of action. By participating in the policy process and conducting studies relevant to social issues, they are contributing to the accumulation of knowledge, thus enhancing their understanding of development as well as improving the nation’s capacity to address the needs of children.

The interest in social policy among mental health professionals was precipitated by a number of developments. One of these was the implementation during the 1960s and 1970s of federally sponsored social programs such as Project Head Start (1,2,3). The proliferation of such programs, and the funds made available for them, enabled researchers and clinicians to apply their knowledge and training to such areas as program development and evaluation, which had not previously received their attention (4,5,6). A related development is that in order to secure funding for research, it is often necessary to demonstrate the practical application of findings and their potential to address societal needs (7).

Another development that fueled the interest in social policy was the recognition that children develop within the social context; they are influenced by various aspects of their immediate environment as well as by the more remote social institutions such as the school, the workplace, government, and the mass media, areas over which children and parents have little, if any, control (8). This realization gave impetus to a number of ecological studies and the compilation of information on children’s behavior, achievement, and physical and mental health (9). On the basis of data generated by these efforts, it has become apparent that an ever-growing number of children and adolescents in the United States face serious problems that often result in mental dysfunction (10).

Child Mental Health Needs: Scope of the Problem

The problem of unmet psychiatric needs in children has been acknowledged for decades, as well as the contributory societal forces needed for proactive policy remedies. A committee of the Institute of Medicine (11), convened at the request of the National Institute of Mental Health (NIMH), studied the mental health status of children and adolescents. It found that at least 12% of children under age 18 (7.5 million children) have a diagnosable mental illness and that many other children exhibit broader indicators of dysfunction, including substance abuse, teen pregnancy, and school dropout, which the committee defined as consequences of or risk factors for developing mental disorders. These findings are echoed in more recent studies. One of these studies estimates that 20% of youths aged 9–17 years have a diagnosable emotional or behavioral disorder and that 9–13% of them suffer from serious emotional disturbances that interfere with their daily functioning (12). Another study focuses on even younger children, indicating that 10% of 3- to 17-year-olds in the United States receive treatment for emotional and behavioral disorders (13).

That so many children are affected by mental disorders suggests that the problem is of national concern. The costs involved in treating mental health disorders are difficult to estimate, in part because of comorbidity with other problems such as substance abuse, making it difficult to separate the costs of care associated with each disorder. Additionally, the information needed to calculate the personal, social, and other costs of childhood mental disorders has not been systematically collected, thus rendering any cost analyses conservative estimates at best. Nevertheless, the studies that are available suggest that the costs of childhood mental disorders are staggering. Rice and colleagues (14) found that treatment services for mentally ill children aged 14 and under exceed $1.5 billion a year. Others suggest that the costs of mental illness in children are much higher since, besides treatment costs, there are indirect costs and costs for nonhealth services, which are borne by families, the schools, the juvenile justice system, and other social institutions (15). As an indication of the costs involved, the estimated direct and indirect cost of mental illness for the total population of the United States was $150 billion in 1996, the latest year for which data are available (16). Clearly, more definitive analyses are needed to establish the actual costs of childhood mental disorders, and such information is important if we are to have a context within which to make decisions about the care of mentally ill children and the allocation of funds to address their needs.

This is a critical issue, given the widely held belief that many children do not have access to mental health services. Two major points are noted in this regard. First, only a small proportion of the overall health budget is directed at children (17). Second, the recent health care reforms that have replaced fee-for-service care with managed care have had both a positive and negative impact on mental health care for children and adolescents. According to the National Health Care Reform Tracking Project (HCRTP), a 5-year study of the impact of managed behavioral health care, access to health services in general has increased for young people (18). However, with the emphasis on brief, problem-oriented approaches, it has become more difficult for children with serious emotional disorders (the “high-utilizers”) and the uninsured to obtain the care needed. Additionally, 90% of health care expenditures for children are consumed by the 15% of children who have chronic illness and disability, leaving little for mental health care. In budget allocation decisions that are made when Medicaid funds are decreased, for example, mental health services are often eliminated.

Contributing Factors at the Community and Family Levels

Perhaps even more significant than the findings on the prevalence and potential costs associated with childhood mental disorders are the findings on the factors that contribute to the development of such disorders. More research is needed to unravel the causes and determinants of childhood mental illness. However, much progress has been made in the past several decades, producing multiple lines of evidence that suggest that a variety of biological, psychological, social, and environmental factors are involved as causal agents, and that in some cases, an interaction between these factors exacerbates vulnerability to mental disorders. Of significance is the fact that in increasing numbers of children, social and environmental risk factors are implicated in the onset of mental dysfunction (19,20). Included among these risk factors are prolonged separations between the parent and child (21), physical or sexual abuse (22,23), poverty (24,25,26), marital discord (27,28), parental psychopathology (29), instability in
the family environment (30), and a variety of other stressors related to family life (11,20,31). Rutter (32) points out that children who experience one of these risk factors may not be any more likely to suffer serious consequences than children with no risk factors. However, the more risks or stressors that are present in children’s lives, the greater the probability of damaging outcomes.

It is also noted that some risk factors compound other problems, such as low birth weight and central nervous system difficulties, which, when they occur in isolation, may have no negative effects. Infant central nervous system difficulties, for example, may be overcome if the child is reared in a stable and supportive environment, but are exacerbated if the child is raised in an unstable, poorly educated, low-income, or otherwise stressful family environment (33,34). Likewise, premature low birth weight babies, who are more vulnerable to environmental insufficiencies than are full-term babies, may experience developmental problems if they are reared by unresponsive adults but may suffer no negative consequences if they receive appropriate care (35).

Poverty

Poverty remains a grave concern, with increasing numbers of families with young children experiencing serious economic problems. This is in part due to the growth in the number of single-parent households, which are the largest and fastest growing family type (36). According to the Current Population Survey in 1998 (37), children under 6 living with a single mother were five times more likely to be poor than those living with both parents. Other contributing factors are cuts in public assistance and the decline in the real value of family income (36,38). The United States provides far less public income assistance to single-parent families than many other industrialized nations (36). Instead, welfare reform initiatives emphasize labor force participation as the route out of poverty. However, whereas in the past, economic prosperity and employment were effective means of reducing the poverty rate, they are no longer sufficient as an antipoverty strategy for single-parent families because of the decline in wage rates, particularly for less skilled workers (36). For example, in the 1980s, each 1% expansion in the aggregate economy correlated with a $.32 decline in weekly wages. Comparing two strong economic years, high school dropouts earned 22% less in 1993 than 1979, while high school graduates earned 12% less. This compares to a rise in income of 10% for college-educated men and 22% for men with post-college degrees (36). For two-parent families, the wage decline has been partly offset by the entry of increasing numbers of women into the labor force, but for single-parent families the escape from poverty is more difficult.

Poverty’s Effects on Children

The decline in real income affects adults and children. However, for children the consequences are particularly serious since, as noted earlier, a significant percentage of families in poverty are those with young children. Indeed, even though the overall poverty rate has declined in recent years, poverty among children under 18 remains high at 18.9%. Children under 6 are particularly vulnerable, with a poverty rate of 20.6% (37).

The ramifications of living in poverty are numerous and include assaults on children’s physical and mental health (39). Klerman (40) found that poor families have no access to health care and that other conditions associated with poverty, such as lack of money to spend on health-promoting activities, hunger, and lack of transportation and adequate housing further exacerbate the problem. As a result, poor children experience more health problems and have a higher mortality rate. In several other studies, it is indicated that there is a powerful, albeit indirect, link between poverty and mental health disorders, leading mental health professionals to the conclusion that poverty is one of the major risk factors in such disorders (26,41,42). Although at one time mental dysfunction, low achievement, and other problems associated with poverty were discussed in terms of assumed negative traits of poor children, researchers now realize that the major sources of psychopathology associated with poverty stem from environmental stresses and feelings of powerlessness and frustration (41,43). Also, it is noted that, among poor families, there is a high incidence of poor prenatal care, low birth weight, and malnutrition (44,45), which are known to contribute to children’s vulnerabilities to environmental stress (11). Parental depression and substance misuse are also heightened among poor families, increasing the risk of child neglect and abuse and contributing to mental health disorders (16,23,46).

Welfare Reform: Effects and Side Effects

The most dramatic piece of legislation for children and families in recent years is the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. By replacing Aid to Families with Dependent Children (AFDC) with Temporary Assistance to Needy Families (TANF), the government effectively reduced public entitlement to cash benefits. States are now granted greater flexibility in the use of welfare funds while obliged to impose work requirements and a 5-year lifetime limit on receipt of federal assistance.

What has been the impact on children and families? The plethora of research studies on the impact of welfare reform reveals success in achieving a 40% reduction in the numbers of dependent families, along with a substantial increase in labor force participation by mothers (47). However, these positive indicators may mask unmet needs. First, a primary implication of increased employment is the need for child care. Research indicates that many parents lack access to high quality care for their children, either through poor provision or because it is too expensive. These findings were highlighted in the first wave of results from a study of the impact of welfare reform in California, Florida, and Connecticut (48). The study noted that the majority of children were in home-based care, and only 13% of this care was deemed to be of good or excellent quality. A second implication of the welfare reform emphasis on employment is that some parents who have difficulty maintaining employment may be rendered ineligible for financial assistance, thus increasing the poverty of their family. For example, the long-term unemployed are likely to require support to maintain their jobs; some poor people, through depression, domestic violence, addictions or mild mental retardation, may be unable to sustain employment. The figures indicating reduction in welfare dependency do not account for those who have been diverted from welfare assistance without entering employment (47). Thirdly, welfare and immigration legislation has reduced access to noncash services such as Medicaid and food stamps, affecting 20% of the children living in the United States (47). Aber and colleagues (49) further indicate that overall welfare reform does not appear to have reduced child poverty, despite the increased levels of parental employment. However, the researchers note that some specific groups, such as children of teen parents, may fare well as long as they are provided with sufficient support services to mediate any negative impact associated with welfare reform.

Parental Psychopathology

A substantial body of literature supports the observation that children of psychiatrically impaired or substance-abusing parents have an increased risk of developing mental health problems compared to children of normal parents (29). It has long been recognized that maternal depression is widespread, particularly among families in receipt of welfare (50). Kagan and Fuller (48) observed in their sample of 948 single mothers with young children, that the incidence of depression was three times higher than the national average, resulting in disengaged parenting practices likely to result in poor development.

Another area of increasing concern is parental substance misuse. There are an estimated 11 million children under the age of 18 with alcohol-dependent parents, and an unknown number of children whose parents abuse drugs (46). Negative influences are transmitted to children through a variety of mechanisms. One leading area of research addresses the consequences of prenatal exposure to cocaine, identifying disruptions to development, such as impaired arousal regulation, which lowers the threshold for coping with stressful conditions (51). Other scholars have documented the relationship between parental substance abuse and subsequent psychopathology in children, emphasizing the role of mediating factors such as family conflict, lack of family rituals, poor home management, ineffective parenting strategies, physical violence, abuse, isolation, stress and frequent family moves (23,46). With rates of drug misuse increasing, it is important to provide medical and social support to families to ensure healthy child development.

Domestic and Community Violence

Another area of particular concern for researchers and policymakers alike is the “epidemic of youth violence (52).” Although exact numbers are hard to quantify, there is little doubt that a large and growing number of children are exposed to violence in their homes, schools, and communities as victims, observers, or perpetrators. For example, a study in New Haven, Connecticut, revealed that 41% of sixth, eighth, and tenth grade students in public schools reported having witnessed at least one violent crime in the past year, and almost all of the eighth graders knew someone who had been killed through violence (53). The findings of such studies are troubling not only because of the threat to children’s safety, but because of the short- and long-term impact on their healthy development. It is not unusual for children exposed to violence to experience disruptions in sleeping, eating, and toileting, and to display generalized fear and flashbacks. Repeated exposure increases the likelihood of depression, anxiety, post-traumatic stress disorder, low school attainment and high alcohol use (52).

There are important policy implications arising from research into the prevalence and effects of exposure to violence among children and youth. Studies of resilience indicate that a key protective factor is a relationship with a caring, responsible adult, usually a parent (54). However, in some instances, parents may be emotionally or practically unavailable to their children, either because they themselves are the victims or perpetrators of violence or because they are numbed by the exposure to violence in their communities. Therefore, the resources of other adults in the community need to be tapped. Research reveals great potential for school-based programs to lead the way in reducing violence among young people and to promote resilience. Other agencies are also well placed to intervene. One example is the Child Development and Community Policing program (CDCP), which fosters collaboration among schools, mental health services, and the police department, and includes training professionals to work within a developmental perspective (52). An evaluation of the program is currently underway, but anecdotal evidence suggests that the CDCP program has resulted in reduced fear of crime, improved relationships between the police and community, increased referrals of children to mental health agencies, reduced rates of violence, and improved adjustment among children (52).

Domestic Violence

Many children also experience violence in their home. While the issue of domestic violence has been on the policy and research agenda for several decades, the impact on children has received less attention. It is estimated that between 3.3 million and 10 million children in the United States are exposed to domestic violence each year (55). While such violence cuts across social strata, it is more prevalent among families living in poverty and is associated with multiple stressors, including substance abuse and other forms of violence. According to recent research, in 30–60% of families experiencing domestic violence, child maltreatment is also present (56). Possible consequences for these children include behavioral problems and depression, and in adulthood they may develop low self-esteem, and resort to violence and criminal behavior (55). Programs do exist in health care, child welfare, mental health, and law enforcement agencies, but rigorous evaluations have not yet measured their effectiveness.

School Violence

Recent media attention has focused on violence in schools (57,58). Although the high-profile incidents of schools shootings are relatively rare, a large number of young people are exposed to violence of varying levels (59). Statistics from the National Crime Victimization Survey (NCVS) and the Youth Risk Behavior Survey (YRBS) indicate a decline in rates of violence, which may be due in part to the proliferation of prevention programs, but rates of violent crime among youth remain high (58,60). The results from a recent study indicated no decrease in feeling too unsafe to go to school, being threatened or injured with a weapon on school property, or having property stolen or deliberately damaged at school (58). In addition to the immediate consequences of exposure to violence, the longer term mental health of young people may be affected. In a survey of 1,100 youth in an urban school, there was a strong correlation between exposure to violence and the development of internalizing and externalizing disorders (59). Children in middle school were found to be particularly vulnerable.

However, while the picture looks bleak, recent violence prevention strategies have yielded promising results. One of the largest and longest running school-based violence prevention programs in the United States—the Resolving Conflict Creatively Program (RCCP)—is currently implemented in over 60 New York City schools and in 12 other school systems across the country (57). The skills taught in the classroom include communicating clearly and listening carefully, expressing feelings and dealing with anger, resolving conflicts, fostering cooperation, appreciating diversity, and countering bias. A recent 3-year evaluation of the program indicated positive outcomes, where an average of 25 lessons were taught in a year, according to child and teacher reports and objective measures.

Family Fragmentation and Mobility

Many children today experience potentially damaging experiences that stem from difficult conditions in family life. During the past 30 years, our society has undergone vast economic and social changes that have transformed the structure of the family and the roles and responsibilities of men and women. These changes have created stressful conditions for children and adults.

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