Is the Mental Health System Failing Troubled Kids?
Spotting, managing young people like the Conn. gunman is difficult and will take more resources, experts say
TUESDAY, Dec. 18, 2012 (HealthDay News) -- In the aftermath of the mass shooting that claimed the lives of 20 children in Newtown, Conn., last Friday, voices around the nation are asking, "How could this have happened?"
At the heart of any answer is the psychological makeup of Adam Lanza, the 20-year-old shooter who forced his way into Sandy Hook Elementary School before gunning down the young students and six adults. Earlier that morning, he shot and killed his mother in the home they shared.
Details of Lanza's mental health issues are still emerging, but it's clear he was a troubled child and young adult. As reported by ABC News, typical comments by people who knew Lanza included "weird kid," "not well" and "hated looking at your eyes."
Mental health experts stressed that merely noting that a child seems "weird" is not enough to mandate that he or she seek care. Most agree, however, that children and young people with mental health issues across the United States are falling through the cracks of an inadequate system.
According to the U.S. National Institute of Mental Health, half of all cases of mental illness begin to develop before the age of 14. Despite this, the United States has a dire shortage of child mental-health providers, said Dr. Howard Liu, medical director of the Behavioral Health Education Center of Nebraska at the University of Nebraska Medical Center in Omaha.
As far back as 2007, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) commissioned a report looking at the issue. "This report found that there were many gaps in the mental health system, including a critical shortage of all child and adolescent providers," Liu said.
In the report's words, "There is a critical shortage of individuals trained to meet the needs of children and youth, and their families. As just one example, the federal government has projected the need for 12,624 child and adolescent psychiatrists by 2020, which far exceeds the projected supply of 8,312. There currently are only 6,300 child and adolescent psychiatrists nationwide, with relatively few located in rural and low-income areas."
The SAMHSA report specifically pinpointed the lack of trained mental health professionals active in the nation's schools, saying that these types of staffers are "in significantly short supply, or are hindered by the constraints of their position to use such skills."
Liu says he deals with these types of shortages every day -- in Nebraska, for instance, there are only 30 child psychiatrists in the entire state, or one for every 11,000 children.
Another expert agreed. "In most places around the country, wait times to be seen by a mental health professional are many months long," said Eric Butter, associate director of the Child Development Center at Nationwide Children's Hospital in Westerville, Ohio.
In addition, many health insurance companies do not adequately cover mental health services, Butter said. This means that people have less access to the psychologists, counselors, clinical social workers and other medical professionals who could prevent them from harming themselves or others.
Both experts stressed that the vast majority of mentally ill people will not act out violently. So spotting and managing those very few who might becomes a hugely difficult task.
"There are several forensic tools which are used in threat assessment for violence, but as any individual working in behavioral health knows, these are imperfect tools which can only give the clinician a general idea of risk," Liu said. "They are certainly no crystal ball for any specific individual."
According to Liu, one study looking into the issue of "risk assessment" for people with schizophrenia, for example, found that to prevent just one homicide a total of 35,000 people with schizophrenia would need to be detained. That is "simply not a reasonable thing to do while respecting our citizens' civil rights," Liu said.
Simon Rego, director of psychology training at Montefiore Medical Center/Albert Einstein College of Medicine in New York City, agreed. "It remains extremely difficult to predict such violent actions," he said.
"People undoubtedly will [and should] look at, among other things, the roles that violent video games, current gun legislation, mental illness and ease of access to mental health care can all play. But the fact of the matter is that most individuals with psychiatric disorders and most young men who play violent video games do not engage in acts of violence," Rego said.
None of this means that parents, schools or mental health care workers should relax their watch over "at-risk" kids or young adults, experts said.
Parents may find it tough to admit that their child has a mental health issue, but getting a child to early treatment is key. "That's difficult for parents to do," Dr. Sandro Galea, chair of epidemiology at Columbia University Mailman School of Public Health, told ABC News.
"I think it's tough to wrap your head around your kids needing treatment for anything, but we may be even more reluctant to accept the notion of mental illness," he said.
Liza Long, who has a 13-year-old son who she says "terrifies" her, caused a firestorm of reaction this week with an article published on her online blog called, "I Am Adam Lanza's Mother." In the article, she described in painful detail her son "Michael's" violent outbursts and difficulties in getting him treatment.
"This problem is too big for me to handle on my own," she said in the article.
Teachers and other school staff remain key players in spotting troubled kids and guiding them to care, but most are not mental health professionals. "Schools cannot prescribe treatments, nor should they," Galea said.
Indeed, the Washington Post reported Monday that officials at Lanza's high school had assigned him a permanent psychologist during his freshman year of 2007, as well as informing the school's chief of security about the boy. But Richard Novia, the director of security at the Newtown School District at the time, told the Post that the concern was for Lanza's safety, not the safety of others.
"At that point in his life, he posed no threat to anyone else," Novia said. "We were worried about him being the victim or that he could hurt himself."
Getting a child with mental illness the care he or she needs can be a "cumbersome" process, as Dr. Jeffrey Lieberman, chair of psychiatry at Columbia University Medical Center in New York City, told CBS News.
He said that even if a person announces specific plans to cause harm, a doctor would need to call law enforcement and fill out reams of paperwork to help contain what may or may not be a real threat.
"In one way, you've got to protect the confidentiality and rights of patients, [on] the other hand, we have a duty to protect society," he said. "Right now, the balance is tipped in favor of the individual against the interests of society."
There's more on mental illness at the U.S. National Library of Medicine.