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A System that Cares

John Sargent M.D., professor of Psychiatry and Pediatrics, vice chair for Child and Adolescent Psychiatry, and director of the Division of Child and Adolescent Psychiatry at Tufts University School of Medicine, went through residency training three times.  

The triple board-certified physician in Pediatrics, General Psychiatry, and Child and Adolescent Psychiatry didn’t do it because he was indecisive or because he loved residency. He did it because he wanted to learn how to best treat his patients whose physical and psychological issues were, in his opinion, inseparable.

“I do what I do because it’s there to be done,” he said at the 9th annual Wiener Lecture in Psychiatry and Behavioral Sciences, December 8. The lecture is named in memory of Jerry Wiener, M.D., who was chair of the GW Department of Psychiatry and Behavioral Sciences from 1977 to 1997.

And with that philosophy, he’s done a lot. According to James Griffith, M.D., professor and interim chair of the Department of Psychiatry in GW’s School of Medicine and Health Sciences, “few individuals have covered such a professional scope in one lifetime.”

During his presentation, “Children’s Mental Health in the 21st Century: Creating a System that Cares,” Sargent reflected on his extensive experience in the field, reviewed statistics about children and adolescents with mental illness, and addressed what changes could be made to better support them.

“A profound transformation needs to take place in how we think about medicine, and how we think about behavioral health,” he said. 

Mental health problems affect 15 to 18 percent of children and adolescents in the United States — about the same amount as those suffering from physical handicaps and chronic illnesses. And yet, mental illnesses receive far less attention and funding, said Sargent.

“America throws away five to 10 percent of children a year. We throw them away,” he said. “We do not give them a future. We lead them to jails, to places of homelessness, to lives of desperation. We do not take care of our children.”

Children with mental health problems also face major educational barriers. For instance, only 30 to 40 percent of children with serious emotional disturbance graduate from high school, and less than 25 percent of children who are five years out of foster care are working or are school. “That is a straight line to poverty — and poverty for the next generation of those children,” said Sargent.

What’s more, disparities in treatment access make it difficult for minority youth to receive care promptly. In effect, sexual minority youth, for example, are eight times more likely to attempt suicide than their peers who are not sexual minorities. They also suffer from higher rates of drug and alcohol abuse and depression.

“All of these problems go away if the family and the community accept the kid,” said Sargent. “They are not inherent to being sexual minority youth; they are inherent in response to discrimination that sexual minority youth experience. And the same I believe is true for cultural, racial, and ethnic minority youth.”

There are many possible reasons for such troubling statistics. First, Sargent said, despite their best intentions, public operations like welfare, juvenile justice, special education, and early identification support systems are often “misaligned, uncoordinated, poorly funded, and, I believe, largely ineffective.”

Health professionals’ priorities can be similarly misaligned, he added, and the care they provide is often episodic when the problems are really longitudinal.

Secondary factors, including how people intuitively respond to children who are emotionally or behaviorally different, can also amplify children’s mental health problems. And, because mental illnesses themselves tend to slow or stop normal development, children afflicted with them can find themselves increasingly lagging behind their peers. “We’re stuck not only treating the problem, but also remediating those differences,” said Sargent.

But Sargent’s lecture wasn’t all gloom. He also detailed ways individuals, communities, and policy makers can improve care for children and adolescents with mental illness. In particular, Sargent emphasized the importance of adult support. Whether in the form of a parent, coach, teacher, or neighbor, children with mental and behavioral health problems need a positive role model who can “navigate the system, access community resources, and foster family empowerment,” he said.

Health care professionals too need to work collaboratively in places like medical homes to provide integrated physical and behavioral care for children and their families. This type of care, however, “demands a change in financing,” said Sargent. For example, professionals should be reimbursed not only for the time they spend with patients, but also for the time they spend talking to one another about mutual patients.

Sargent also advocated for mental illnesses to be approached from a prevention standpoint. Instead of treating the illness and its side effects, physicians should screen for risk factors including domestic violence, parental depression, and substance abuse, he said.

“Our ultimate goal is to move the kids on the margin into the middle,” he concluded. “To stop throwing away five to ten percent of children annually, to build inclusiveness with respect to all forms of difference, and work toward the best possible outcome for each child and family.”