Presidential Column

Enhancing services for children and families: Policy, research, practice, advocacy, and education

The need for a comprehensive system of care for children, adolescents and their families is greater than ever.

By Michael C. Roberts, PhD

Of the three million seriously disturbed children in this country, two-thirds are not getting the services they need. Countless others get inappropriate care. These children are “unclaimed” by the public agencies with responsibility to serve them. (Knitzer, 1982, p. ix)

Thirty years ago, psychologist Jane Knitzer prepared the Children’s Defense Fund (CDF) monograph entitled “Unclaimed Children.” This treatise was a comprehensive detailing of American failures to meet the mental health needs of children, and their families. Knitzer and CDF called for systemic changes on a comprehensive scale to identify the large numbers of children in need of services or receiving inappropriate services. Although many services were simply unavailable for those in need, she also noted that those services that did exist were fragmented and generally uncoordinated. There was insufficient attention to preparing professionals to meet the needs. Knitzer’s writing was powerful and had significant impact. Ten years later, she indicated that some progress could be discerned, but many of the concerns raised in Unclaimed Children remained (Knitzer, 1993).

Over the years, Knitzer was not alone in her identification of poor mental health services for children; numerous research reports and not just a few governmental reports articulated similar findings (e.g., the report of the Office of Technology Assessment by Saxe et al., 1986; the report of the National Commission on Children in 1991 entitled Beyond Rhetoric; the Healthy People reports from the Department of Health and Human Services, 2000; and the President’s New Freedom Commission report in 2003).

Thirty years after Unclaimed Children, children and families in the United States are still in significant need of mental and physical health services and not receiving what they need. Div. 37 was founded in 1978 to reach across all the divisions with their parochial interests and find common cause to advance children’s issues. The need for this division and activist members has never been greater. Our work in enhancing child and family services remains as a life’s work for us all, in the areas of Policy, Research, Practice, Advocacy, and Education.

Policy

Unfortunately, over this period of time in the years since Knitzer’s monumental work, the situation has been a mixed bag of some improvements and more back sliding. There are hopeful signs of improvement in some areas while other areas have deteriorated by many markers. Through the years, social policy regarding children might be best categorized as a “work in progress.” Nonetheless, the issues of public and private services for children have evolved as recognition that children are vulnerable has risen in the public consciousness. Milestones of policy progress can be pointed to-- and there were outcries of opposition. These are eerily similar to those who wanted things to stay the same when child labor laws and child protection laws were passed, because those governmental actions were considered intrusions on corporate and family rights to do what they wanted to do with little or no regulation and interference from governments.

Many members of this division might already know of the reports I cited above, but what I find problematic is that there are just too few policy analyses readily available to psychologists through the typical information channels of the profession of psychology, including developmental, school, clinical child, pediatric or any other specialty. For example, there are few policy analyses in the Journal of Clinical Child and Adolescent Psychology, Developmental Psychology, and Journal of Pediatric Psychology. These are high-quality scientific journals, but I suspect policy pieces get triaged out either by editorial action or because authors feel they will not be well received. Some excellent policy analyses from psychologists are published elsewhere (such as the Social Policy Reports of the Society for Research in Child Development) and might be found if one searches, but these are not readily available to many who might benefit.

Where do trainees and professionals learn about policy issues, how to study them, and how to advocate on them? Most will not have the opportunity to study at a policy institute or be able to search for easy to use policy information given the many demands on their time and other needs, such as making a livelihood. As noted on the email list, the division website, and The Advocate, the division will be copublishing a series of policy and literature review briefs with Springer Publishing Corporation under the title of Advances in Child and Family Policy and Practice in its SpringerBriefs series.

The Division Board approved this venture to become a useful resource for members of the division in providing information about policy, research, and practice in children’s services at no cost for access by division members.

Research

The discipline of psychology, based on science, needs a convincing database of information and logic to direct decision making. In particular, one purpose of this Division, according to the By-Laws, is “to promote the application of developmental and ecological theory and research as a basis for prevention and intervention efforts with children, youth, and families” and “to stimulate the development of research initiatives on professional and policy issues concerning children, youth, and families by highlighting what is known and what needs to be known about these issues” (Society for Child and Family Policy and Practice, 2010). There has been a strong focus of energy and attention in applied psychology on empirically supported treatments and evidence-based practice; this is important work but what is missing in this type of research is sufficient attention to the organizational structure of mental health services to be able to effectively deliver psychosocially based treatments. There are some excellent centers examining mental health systems and service delivery, but most clinical, school, and counseling psychology programs do not train in these forms of research and analysis. In my view, all too often faculty are perpetuating what makes their own careers successful by studying relatively small issues with easily measured variables that lead to statistically significant results. My own vita has examples of this form of academic productivity. Unfortunately, we have diverted attention from real world settings. This is what Cook and Shadish (1986) called “the worldly science” (p. 193), that is, research in applied settings, which can be often messy compared to the cleaner “bench sciences” of some psychological domains. Fortunately, some psychologists are conducting research that is meaningful and relates to the issues of children’s services. In the summer of 2012, a superb special section of the American Journal of Community Psychology published 15 articles and two commentaries on “Systems of Care” for children, adolescents, and their families (volume 49, issues 3-4). The articles demonstrate how systems of care can be modified to “support more positive child and family outcomes” (Kilmer & Cook, 2012, p. 580) and describe implementation research that documents effectiveness. More of this type of work is needed; the new Advances in Child and Family Policy and Practice would be an excellent outlet in which to publish it.

Practice

These comments on research lead directly to practice considerations--actual implementation with real people in real settings. These applications can be with individuals with whom psychologists work directly in a clinical practice –although “practice” in the division terminology does not mean just clinical practice. Our practice definition must include applications of biopsychosocialeducational interventions and programming that serve, support, and optimally develop children and families. The social ecological model is endorsed by many in the division and emphasized in the division’s stated purposes. This definition of practice includes all settings that surround a child, including family, school, peers, juvenile justice and the courts, social welfare, mental health and behavioral health, physical health and safety, community agencies and youth development activities, and federal/international entities.

Practice at all levels should be guided by research—and decisions should be made, as articulated by Tolan and Dodge (2005) on the basis of “rigorous efficacy trials and tested in community-based effectiveness trials...‘Best practice’ without adequate evaluation and research is in itself an indictment of the inadequate research infrastructure in children’s mental health. What is needed is practice that follows scientific evidence...” (p. 603).

Advocacy

This division is committed to advocacy on behalf of children and families in addition to advancing services and service delivery structures. One of the stated purposes in the Bylaws is to provide for “child, youth, and family advocacy in order to bring about those social changes consistent with psychological knowledge that will promote the well-being of children, youth and families” (Society for Child and Family Policy and Practice, 2010). Advocacy is broadly conceptualized as a process of informing and assisting decision makers,…[which] entails developing active ‘citizen psychologists’ who promote the interests of clients, health care systems, public health and welfare issues, and professional psychology…More specifically, advocacy initiatives may include helping those who are underserved access care, promoting social justice through the recognition of diversity and multicultural issues, securing funding for training and research, and understanding and becoming involved in public policy issues that affect the profession at local, state, and national levels (Lating, Barnett, & Horowitz, 2009, p. 106).

The division is committed to advocacy, but a question should always be raised when we say we need to advocate: Advocacy for what? There can be well trained, articulate, and powerful advocates for the direct opposite of what many in the division might think are the most important issues of the day. So, I urge a careful approach to advocating for advocacy without context. But if one does the proper policy analysis, conducts research and builds an evidence base with objectivity (not ideology), and examines practices of providing services for children and families, then the professional can come to constructive, research-based conclusions and make strong advocacy positions. These might include, for example, advocating for integrated medical and mental health services for children and their families in comprehensive, family-centered, culturallycompetent, and evidence-based approaches (such as advocated by Knitzer in 1982 after a careful analysis of data). I firmly believe that these approaches would meet both conservative and liberal agendas—that is, save money in the long-run and reduce misery in the short- and long-term. Advocacy means becoming knowledgeable on the issues and can take many forms as I noted in the summer issue of The Advocate. Being an advocate means being a persistent and insistent voice on behalf of children—just as Jane Knitzer would have wanted us to do.

Education

The new competencies listed for education and training in professional psychology now explicitly include “Advocacy” preparation. For example, the Competency Benchmarks for Professional Psychology list “Advocacy–Actions targeting the impact of social, political, economic or cultural factors to promote change at the individual (client), institutional, and/or systems level.” Doctoral training programs in professional psychology are being asked to assess using the Competency Benchmarks in Professional Psychology Rating Form how well a trainee at various levels (practicum, internship, and entry to practice) performs on certain characteristics such as “Uses awareness of the social, political, economic or cultural factors that may impact human development in the context of service provision,” and “Intervenes with client to promote action on factors impacting development and functioning.” Further, in terms of Systems Changes, how well the trainee “Understands the differences between individual and institutional level interventions and system’s level change,” “Promotes change to enhance the functioning of individuals,” and “Promotes change at the level of institutions, community, or society.” It will be important to observe how advocacy training is implemented in professional psychology education over the next few years—I hope this will be invigorating and effective but am not sure that all trainers are convinced of the need for this training or personally knowledgeable enough to provide the training and experiences necessary.

Div. 37 members have an opportunity to provide resources to create new generations of professionals with basic skills in advocacy. The division sponsored handbook entitled Child and Family Advocacy: Bridging the Gaps Among Research, Practice and Policy and edited by Anne Culp (in development) will likely be published by Springer in 2013. This will be a remarkable resource for all.

Advocacy training, in the abstract is, at best, a promise, a potential; it requires followthrough and a strong foundation in policy analysis, research, and practice knowledge to make it “real” and powerful. It involves not just having the research to support a position, but learning to shape and manage the message to decision-makers and the public.

At the 2012 APA Convention, there were many division-sponsored activities devoted to advocacy, including a symposium called “Bridging the Gap Between Research and Policy in Children's Mental Health: The Importance of Framing.” This symposium built on the Summit of the InterDivisional Task Force on Children’s Mental Health and presented amazing advocacy information developed by the FrameWorks Institute. The division also held a “Conversation Hour on Advocating for Children: A Mentoring Breakfast for Students Interested in Policy.” Other division sponsored programs conveyed significant information relevant to advocacy. On Oct. 18, 2012, the Division sponsored a Workshop on “Becoming a Strong Advocate for Children” (co-sponsored with APA and the division’s Section on Maltreatment) at the National Conference in Clinical Child and Adolescent Psychology (which is co-sponsored by Div. 53, Society of Clinical Child and Adolescent Psychology). The workshop leaders were Nina Levitt of the APA Governmental Operations office—and Brian Wilcox of the University of Nebraska Center on Children, Families, and the Law (a renowned child advocate as well as a former president of this division).

Conclusions

Reflecting back over the 30 years since Jane Knitzer and the Children’s Defense Fund’s Unclaimed Children, there is a consensus that what is needed is a system of mental health care for children that overcomes multiple obstacles to become a comprehensive system of care— finally adequate to meet the needs of children, adolescents, and their families. The need for this Division and individuals, trainees and professionals, as activist members, has never been greater. Clearly, our most important work remains still ahead, in the area of enhancing children’s services through Policy, Research, Practice, Advocacy, and Education—I look forward to working with you.

As a historical note, Jane Knitzer received the Division’s award for advocacy, the Nicholas Hobbs Award, in 1984 and served as our President in 1996. She died in 2009 and her articulate and insistent voice is missed.

References

Cook, T. D., & Shadish, W. R. (1986). Program evaluation: The worldly science. Annual Review of Psychology, 37, 193-232.

Culp, A. (Ed.). (In development). Child and family advocacy: Bridging the gaps Among research, practice and policy. New York: Springer.

Department of Health and Human Services. (2000). Healthy people 2010. Retrieved from www.healthypeople.gov.

Kilmer, R. P., & Cook, J. R. (2012). Moving forward with systems of care: Needs and new directions. American Journal of Community Psychology, 49, 580-587.

Knitzer, J. (1982). Unclaimed children: The failure of public responsibility for children and adolescents in need of mental health services. Washington, DC: Children’s Defense Fund.

Knitzer, J. (1993). Children’s mental health policy: Challenging the future. Journal of Emotional and Behavioral Disorders, 1, 8-16.

Lating, J. M., Barnett, J. E., & Horowitz, M. (2009). Increasing advocacy awareness within professional psychology training programs: The 2005 National Council of Schools and Programs of Professional Psychology Self-Study. Training and Education in Professional Psychology, 3, 106-110.

National Commission on Children. (1991). Beyond Rhetoric: A New American Agenda for Children and Families. Final Report of the National Commission on Children. Washington, DC: US Government Printing Office.

President’s New Freedom Commission on Mental Health. (2003). President’s new freedom commission on mental health: Background information. Retrieved from www.mentalhealthcommission.g ov/background.html.

Saxe, L. M., Cross, T., Silverman, N., & Batchelor, W. F. (1986). Children’s mental health: Problems and services. Washington, D.C.: Office of Technology Assessment.

Society for Child and Family Policy and Practice; Division 37 of the American Psychological Association. (2010, December). Bylaws.Washington, DC: Division 37.

Tolan, P. H., & Dodge, K. A. (2005). Children's Mental Health as a Primary Care and Concern: A System for Comprehensive Support and Service. American Psychologist, 60, 601-614.