Why substituting "behavioral" health care for "mental" health care is wrong

A colleague of mine recently pointed out a study by the Center for Health Care Strategies (CHCS) about mental health care for children. Among their findings was this

• Almost 50 percent of children enrolled in Medicaid who are prescribed psychotropic medications receive no identifiable behavioral health treatment.

This is a disturbing, though not surprising, statistic given that these medications are commonly prescribed by primary care clinicians. Children living in poverty often experience greater environmental stress and may have greater mental health care needs, and the study points to medicaid as a possible source for improved, and presumably preventive, care.

Children with significant behavioral health needs typically require an array of services to support their physical, intellectual, and emotional well-being. These children, however, are often served through fragmented systems, leading to inefficient care, costly utilization, and poor health outcomes. As a significant source of funding for children’s behavioral health care, Medicaid programs can advance fundamental improvements in care coordination and delivery for these vulnerable children.

This would certainly be a goal to work towards.

However, in reading about this study I was distracted by, and am struggling with as I write, the repeated reference to "behavioral health care" rather than "mental health care." This change in language is now common in our culture. It is significant and worrisome for two reasons.

First, it serves to perpetuate the stigma of mental illness. Implied in this word substitution is the idea that mental illness is something that should not be talked about.

Recently I came up against this stigma when giving a talk that included a discussion of the connection between "colic" and perinatal emotional complications such as anxiety and depression. An audience member, a mother of several grown children, spoke of resentment, that was still very much alive over 20 years later, that her friends and colleagues had been concerned about her mental well being when caring for her first very challenging child.

Severe sleep deprivation, feelings of isolation and low self esteem are an almost inevitable consequence of having a very fussy baby. The stigma associated with identifying this constellations of concerns as a "mental health problem" is part of the reason for inadequate identification and treatment of postpartum depression and anxiety.

Research has shown that when untreated, these problems can in turn lead to mental health problems in the developing child. If we could, as the saying goes "call a spade a spade," without having it be associated with blame and shame, there might be more hope for helping for these mothers, and for preventing the development of mental health problems in their children.

The second, and perhaps more worrisome issue related to the substitution of "behavioral" for "mental" is the idea that treatment involves controlling behavior, rather than understanding the meaning of behavior.  The ability to attribute motivations and intentions to behavior is a uniquely human quality. Extensive research, that I describe in my book Keeping Your Child in Mind has shown that children develop a healthy sense of self, the capacity for emotional regulation, flexible thinking, social engagement, and overall mental health, when the people who care for them think about and understand the meaning of their behavior. In contrast, there may be significant disturbances when there is an absence of such curiosity about a child.

This brings us full circle to the problem identified by the above study. By treating these children with psychiatric drugs with no other form of treatment, there is no room for curiosity or understanding. Children living in poverty, especially those in foster care, may have experienced significant early trauma and loss. The consequences of treating the behavior alone, in these and other circumstances can be significant. For example, a recent long-term follow up study of children diagnosed with "ADHD" treated with "behavior management" and medication showed that there was a five times higher risk of suicide, and 3% of adults at follow up were in prison.

The CHCS study calls for "expanding access to appropriate and effective behavioral health care." For it to be appropriate and effective, we need to call it mental health care. It needs first and foremost to allow for time and space for listening, for understanding the meaning of behavior.

Addressing the question: Is something wrong with my child?

In the setting of my behavioral pediatrics practice, this can be a loaded question. One would assume that parents are hoping very much for the answer to be "no." But they wouldn't be in my office if there weren't something wrong. Therefore if I say "no," parents may be left feeling there is something wrong with them.  At moments like this, I turn to the growing discipline known as "infant mental health." (Here infant refers to children under age five.) Charles Zeanah, MD, in the Handbook of Infant Mental Health writes: 

The relational focus of infant mental health has been the sine qua non of this field from the beginning. It is not the infant who is the target of intervention but rather the infant-parent relationship. . . . Instead of the problem or disturbance being understood as within the child or within the parent, the problem may be understood as between the child and caregiver.

The child brings his or her own qualities to the relationship, qualities referred to as "biological vulnerabilities." These may include difficulties with sensory processing and inflexibility. The parent brings his or her own issues, which include not only biological vulnerabilities, that in adult life may manifest as actual mental illness, but a whole history of relationships and experience.

"Infant mental health" can be a confusing term, as it may imply that there is such a thing as "infant mental illness." As those who read my blog know, I am very much opposed to diagnosing mental illness in young children.  Rather, infant mental health is about understanding and supporting the young child's ability to experience, regulate and express emotions, form close relationships, and explore the environment and learn.

Many forces, including the education system and health insurance industry, push parents in the direction of answering the above question in the form of a diagnosis. On a purely emotional level, during the time it takes to  address the problems in the relationship (and it does take time, but for a young child, not that much time) it can be hard to hold on to the complexity. The need to answer this question with a definitive "yes" or "no" may be put aside, only to resurface at a later time.

Daphne Merkin, in last week's New York Times piece Is Depression Inherited? tackles this challenging issue. Merkin, who has had a lifelong struggle with depression, looks at the question from her perspective as mother to a now 22-year-old daughter. She writes:

Probably the most basic error we make is in trying to frame the puzzle of how human character evolves in stark oppositional terms — nature or nurture — rather than seeing it as an inextricable mix of things.

Her most important point comes in a parenthetical statement. In considering how to use the current information available to guide parenting, she writes:

Until more compelling genetic information becomes available, it seems that the best we can do is to keep our children’s predispositions in mind while focusing on the pieces of the developmental puzzle over which we can exert control. (This includes being attuned to your child’s nature, especially when it differs from your own.)

 This last concept of "being attuned to your child's nature, especially when it differs from your own,"  is the essence of healthy parenting. She is describing a parent's recognition of what D. W, Winnicott termed the child's "true self." It involves recognizing a child as a person with thoughts and feelings that are his own. It is an excellent goal to work towards, though not always easy.   Issues that get in the way of recognizing the child's true self, including stresses in a parent's life and other relationships, may need to be addressed.

When viewed from this perspective, the question becomes not "is there something wrong with my child?" but rather "Who is this child, and how is he or she both alike and different from me?"

As I write in my book Keeping Your Child in Mind, where I explore this issue in much more depth:

It is my hope that we can move from an emphasis on diagnosis and labeling to an emphasis on prevention. We need to ask not “what is the disorder?” but rather, “what is the experience of this particular child and family?” and “what can we do to move things in a better direction?”