In the Trenches of a Crisis

The Need for Children's Emotional HealthLink

In Boston, one child in five at high school has considered suicide, and 8 percent attempted suicide in 1999. These statistics, released in 2001 by the Boston Health Commission, underscore the consequences of late diagnosis of mental disorders. Many mental illnesses are caused by family violence: a study at Boston City Hospital (now Boston Medical Center) showed that one child in ten had witnessed a knifing or shooting by the age of six, and Boston Medical Center estimates that across the nation, this year, between 3 and 10 million children will witness violence. Karen Powers, a counselor in Boston schools, has seen one or two children each week who have made either a suicide attempt or a plan. "They feel hopeless," she reports.

Pediatricians and family physicians work in the trenches of this crisis. They see increasing numbers of depressed and anxious children. Many young patients come from a background of physical or sexual abuse, and a rising number attempt suicide. According to CDC, between 1952 and 1995 the incidence of suicide among adolescents and young adults nearly tripled, and there was a steep increase in suicides of children between 10 and 14.

The human cost of this suffering is incalculable. The fiscal costs are staggering: the AMA reports that the estimated cost of depression in the U.S. is $43 billion per year. About 30 percent is the cost of treatment, with the remainder due to premature death and lost productivity. The lost children of today are the lost adults of tomorrow.

"Some studies have shown that only one third of parents who had psychosocial concerns about their children planned to discuss them with their pediatrician. When parents did initiate this discussion, only 40 percent of pediatricians responded.[…] This finding indicates that the vast majority of psychosocial disorders in children are being missed, potentially at a time when appropriate evaluation and treatment could prevent or ameliorate the significant subsequent morbidity and mortality associated with them. It is important that screening measures be implemented to help identify children in need."

- Sung E. Son, M.D., Jeffrey T. Kirchner, D.O., Depression in Children and Adolescents, American Family Physician, November 15, 2000

According to the American Medical Association (AMA) the general population has about a 20 percent lifetime risk for the development of depression. In the U.S., about 75 percent of those who seek help for depression go to a primary care physician (including pediatricians) rather than a mental health professional.

Experts suggest that screening for depression in a careful clinical interview has a degree of "sensitivity and specificity" comparable to a number of routine radiologic and laboratory tests. Several screening tools are available for family physicians to help diagnose adult patients with mental disorders—but few even general guidelines are available for pediatricians.

In addition to parental denial, social stigma, and substance abuse, barriers to an early diagnosis of depression, anxiety and other emotional disorders in children may include family or sexual violence. In 1996, the American Psychologist Association reported that one woman in three will experience assault from an intimate in her adult lifetime. Yet the National Coalition Against Domestic Violence estimates that only one in seven cases of domestic assault are reported to police. (Reporting is often much lower for foreign-born women, who fear deportation by their spouse or the government if they report.) Effects of exposure to violence in children include depression, aggression, phobias, insomnia and poor academic performance. Exposure to extreme violence may lead to posttraumatic stress disorder. Yet family violence is no easy secret for a parent to reveal to a physician, and sexual abuse is even harder to diagnose, for typically the parent is unaware of it.

Another major barrier to diagnosing mental disorders in children is language and culture. Currently, the U.S. Census Bureau reports the largest wave of immigration in U.S. history. In 2002, over 33 million U.S. residents were foreign born—more than the population of Canada. One child in five is an immigrant or an immigrant's child. Census figures for Boston show that in 2000 nearly 26 percent of the population (one in four) was foreign born while 16.3 percent were Limited English Proficient. Extrapolating from national statistics, we can infer that one child in two in Boston—and one in four in greater Boston—is an immigrant or an immigrant's child. The greater Boston area showed a robust foreign-born population of 13.5 percent, ranking it fifth across the nation for immigrant populations in metropolitan areas of over 5 million .

With immigrants in the U.S. speaking over 300 languages, experts concur that many families will need trained, professional interpreters to protect their children's mental health. Cultural barriers may include lack of understanding about the health care system; cultural stigma about mental illness; the difficulty of female patients opening up to male physicians (and vice versa); and fear of deportation if families have no permanent residence. In many Asian cultures, mental illness is deeply hidden, something to be dealt with inside the family. A number of cultures fear "loss of face" if word about mental illness in the family leaks out to their community. Some believe that pain of any kind should simply be endured. Intercultural family dynamics are also complex, for example, when children grow Americanized and speak fluent English but parents cleave to the old culture and cannot learn English. All such cases require experts in cross-cultural health, who are typically interpreters or cultural mediators specially trained to address these issues.

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I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center,  and the families of my medical practice. 

I hope you find this site useful and encourage any comments.

- Dr. Howard King, M.D.