spacer spacer spacer spacer spacer spacer spacer

Connect With Us

Ask the Expert

June Ask the Expert

Pierluigi Mancini

06 Prevention and Early Intervention in Behavioral Health

Ask the Expert: 

Of Colombian and Italian descent, Dr. Mancini has been helping people in Georgia recover from mental illness and addiction since 1985. With degrees in psychology and business, and personal experience as a person in long term recovery from addiction, Dr. Mancini has directed his energies to helping the Latino community since 1999. Through his work, he helps the Latino community understand and seek help for mental illness and addiction through prevention and education programs, and direct counseling services.

Dr. Mancini serves as a Board member on the Grady Memorial Hospital Corporation, and the Healthcare Georgia Foundation’s Board of Directors. He is the President of the Board of the National Latino Behavioral Health Association, and serves as Chairman Emeritus of the State of Georgia Mental Health Planning and Advisory Council.

Dr. Mancini has been honored with the  2010 Georgia Kidsnet Academy III SOC – Individual Partner Award; the 2009 Hispanic Health Coalition Salud Hispana Award; the 2008 NAACP Gwinnett – Health Services Award; the  2008 – Catalyst for Care – Outstanding Leadership Award and the  2007- Mental Health America “Heroes in the Fight”  Award.

A frequent guest of CNN en Español, Dr. Mancini is the founder and Chief Executive Officer of CETPA, a nonprofit organization dedicated to providing affordable, linguistic and culturally appropriate behavioral health services to the Latino community in Georgia. CETPA is the only Latino behavioral health agency in Georgia to earn state licensing and national accreditation to provide integrated services in English and in Spanish.

Dr. Mancini is also the President of the Multicultural Development Institute, Inc., an organization dedicated to bridging the gap between cultures, affecting access and delivery of services through education and training.

1) Question: Our daughter is finally on the road to recovery, now 10 months sober/clean and in a transitional program in Tennessee. It took her almost 10 years to get to this point and it has cost us enormously in retirement funds, and in our health and wellbeing. While I'm grateful for her recovery, I am reminded daily that few can do what we finally did - pay out of pocket for intensive treatment (over $100,000 at this point). How do we, as a nation, do better when doctors refuse to listen to family members, insurance companies refuse to pay, and psychiatrists rely solely on psychotropic drugs instead of behavioral approaches to uncover the real problems? How do we begin to fix this broken system to truly help those in need and the families that support them?

Answer: Your love and dedication toward the well-being of your daughter is exemplary and should not go unnoticed.  I believe that it is by examples like yours that others become stronger since your story promotes hope. 

The National Institute on Drug Abuse (NIDA) – -states that drug addiction is a complex illness characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. While the path to drug addiction begins with the voluntary act of taking drugs, over time a person's ability to choose not to do so becomes compromised, and seeking and consuming the drug becomes compulsive. This behavior results largely from the effects of prolonged drug exposure on brain functioning. Addiction is a brain disease that affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior.

Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual's life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is typically a chronic disease, people cannot simply stop using drugs for a few days and be cured. Most patients require long-term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives.

Too often, addiction goes untreated: According to SAMHSA's National Survey on Drug Use and Health (NSDUH), 23.2 million persons (9.4 percent of the U.S. population) aged 12 or older needed treatment for an illicit drug or alcohol use problem in 2007. Of these individuals, 2.4 million (10.4 percent of those who needed treatment) received treatment at a specialty facility (i.e., hospital, drug or alcohol rehabilitation or mental health center). Thus, 20.8 million persons (8.4 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive it. These estimates are similar to those in previous years.

When discussing effective treatment, NIDA shares that scientific research since the mid–1970s shows that treatment can help patients addicted to drugs stop using, avoid relapse, and successfully recover their lives. Based on this research, key principles for effective treatment have emerged that should form the basis of any effective treatment programs.  They are:

- Addiction is a complex but treatable disease that affects brain function and behavior.

- No single treatment is appropriate for everyone.

- Treatment needs to be readily available.

- Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.

- Remaining in treatment for an adequate period of time is critical.

- Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment.

- Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

- An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.

- Many drug–addicted individuals also have other mental disorders.

- Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long–term drug abuse.

- Treatment does not need to be voluntary to be effective.

- Drug use during treatment must be monitored continuously, as lapses during treatment do occur.

Treatment programs should assess patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk–reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases.

When discussing treatment approaches we must look at medication and behavioral therapy, especially when combined, as important elements of an overall therapeutic process that often begins with detoxification, followed by treatment and relapse prevention. Easing withdrawal symptoms can be important in the initiation of treatment; preventing relapse is necessary for maintaining its effects. And sometimes, as with other chronic conditions, episodes of relapse may require a return to prior treatment components. A continuum of care that includes a customized treatment regimen—addressing all aspects of an individual's life, including medical and mental health services—and follow–up options (e.g., community – or family-based recovery support systems) can be crucial to a person's success in achieving and maintaining a drug–free lifestyle.

The use of medications can also bring healthy discussions and sometimes disagreements. Medications can be used to help with different aspects of the treatment process.

Medications during Withdrawal: Medications offer help in suppressing withdrawal symptoms during detoxification. However, medically assisted detoxification is not in itself "treatment"—it is only the first step in the treatment process. Patients who go through medically assisted withdrawal but do not receive any further treatment show drug abuse patterns similar to those who were never treated.

Medications as part of Treatment: Medications can be used to help reestablish normal brain function and to prevent relapse and diminish cravings. Currently, we have medications for opioids (heroin, morphine), tobacco (nicotine), and alcohol addiction and are developing others for treating stimulant (cocaine, methamphetamine) and cannabis (marijuana) addiction. Most people with severe addiction problems, however, are polydrug users (users of more than one drug) and will require treatment for all of the substances that they abuse.

Medications for Opioids: Methadone, buprenorphine and, for some individuals, naltrexone are effective medications for the treatment of opiate addiction. Acting on the same targets in the brain as heroin and morphine, methadone and buprenorphine suppress withdrawal symptoms and relieve cravings. Naltrexone works by blocking the effects of heroin or other opioids at their receptor sites and should only be used in patients who have already been detoxified. Because of compliance issues, naltrexone is not as widely used as the other medications. All medications help patients disengage from drug seeking and related criminal behavior and become more receptive to behavioral treatments.

Medications for Tobacco Cessation: A variety of formulations of nicotine replacement therapies now exist—including the patch, spray, gum, and lozenges—that are available over the counter. In addition, two prescription medications have been FDA–approved for tobacco addiction: bupropion and varenicline. They have different mechanisms of action in the brain, but both help prevent relapse in people trying to quit. Each of the above medications is recommended for use in combination with behavioral treatments, including group and individual therapies, as well as telephone quitlines.

Medications for the treatment of Alcohol Dependence: Three medications have been FDA–approved for treating alcohol dependence: naltrexone, acamprosate, and disulfiram. A fourth, topiramate, is showing encouraging results in clinical trials. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and in the craving for alcohol. It reduces relapse to heavy drinking and is highly effective in some but not all patients—this is likely related to genetic differences. Acamprosate is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria (an unpleasant or uncomfortable emotional state, such as depression, anxiety, or irritability). It may be more effective in patients with severe dependence. Disulfiram interferes with the degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. Compliance can be a problem, but among patients who are highly motivated, disulfiram can be very effective.

But medication assisted treatment is only part of the equation. Behavioral treatments help patients engage in the treatment process, modify their attitudes and behaviors related to drug abuse, and increase healthy life skills. These treatments can also enhance the effectiveness of medications and help people stay in treatment longer. Treatment for drug abuse and addiction can be delivered in many different settings using a variety of behavioral approaches.

Outpatient behavioral treatment encompasses a wide variety of programs for patients who visit a clinic at regular intervals. Most of the programs involve individual or group drug counseling. Some programs also offer other forms of behavioral treatment such as—

Cognitive–behavioral therapy, which seeks to help patients recognize, avoid, and cope with the situations in which they are most likely to abuse drugs.

Multidimensional family therapy, which was developed for adolescents with drug abuse problems—as well as their families—addresses a range of influences on their drug abuse patterns and is designed to improve overall family functioning.

Motivational interviewing, which capitalizes on the readiness of individuals to change their behavior and enter treatment.

Motivational incentives (contingency management), which uses positive reinforcement to encourage abstinence from drugs.

Residential treatment programs can also be very effective, especially for those with more severe problems. For example, therapeutic communities (TCs) are highly structured programs in which patients remain at a residence, typically for 6 to 12 months. TCs differ from other treatment approaches principally in their use of the community—treatment staff and those in recovery—as a key agent of change to influence patient attitudes, perceptions, and behaviors associated with drug use. Patients in TCs may include those with relatively long histories of drug addiction, involvement in serious criminal activities, and seriously impaired social functioning. TCs are now also being designed to accommodate the needs of women who are pregnant or have children. The focus of the TC is on the resocialization of the patient to a drug-free, crime–free lifestyle.

There is also treatment in a criminal justice setting that can succeed in preventing an offender's return to criminal behavior, particularly when treatment continues as the person transitions back into the community. Studies show that treatment does not need to be voluntary to be effective.

The above referenced data is from the National Survey on Drug Use and Health (formerly known as the National Household Survey on Drug Abuse), which is an annual survey of Americans age 12 and older conducted by the Substance Abuse and Mental Health Services Administration. This survey is available online at and from NIDA at 877-643-2644.

As far as coverage for substance abuse issues, I can share that substance abuse treatment generally falls under an insurance plan's mental and behavioral health coverage. For many group health insurance plans (such as those offered by employers), the Mental Health Parity and Addiction Equity Act comes into play.

This act requires group health insurance plans covering more than 50 employees to make sure their coverage for mental health issues is equal to that of their coverage of physical health issues, according to the U.S. Department of Labor. Group plans are not required to include mental health coverage -- but, if they do, coverage cannot be more restrictive than it would be for medical and surgical care. Moreover, these group plans are not allowed to have separate deductibles, restrictions on the number of visits and higher co-payments for mental health care.

The Mental Health Parity and Equality Act did not, however, apply to small businesses with fewer than 50 employees or to individual health insurance policies. Some individual policies do offer mental health insurance coverage, including substance abuse treatment. And about two-thirds of substance abuse treatment centers accepted private insurance as of 2008, according to a January 2011 survey.  But it has been difficult to implement and to regulate.

The good news is that the Patient Protection Affordable Care Act (ACA) signed into law on March 23, 2010 (P.L. 111-148) put in place comprehensive health insurance reforms that will make health insurance available to many more people, lower health care costs, guarantee more health care choices, and enhance the quality of health care for all Americans. 

The ACA includes substance use disorders as one of the ten elements of essential health benefits. This means that all health insurance sold on Health Insurance Exchanges or provided by Medicaid to certain newly eligible adults starting in 2014 must include services for substance use disorders.

By including these benefits in health insurance packages, more health care providers can offer and be reimbursed for these services, resulting in more individuals having access to treatment. The specific substance abuse services that will be covered are currently being determined by the Department of Health and Human Services, and will take into account evidence on what services allow individuals to get the treatment they need and help them with recovery.

Misconceptions about addiction include the fact that substance abuse all too often is discounted as a serious disease. Although more thorough substance abuse treatment is expensive, so is allowing addiction to go untreated. Drug and alcohol abuse strains the economy, the health care system and the criminal justice system. According to the White House office, drug abuse cost the United States $193 billion in 2007.

For some, turning to family, friends and free local addiction groups for substance abuse help can be extremely beneficial -- but others need more specialized care. Making substance abuse care more widely available could provide addicts a better path to recovery.

Finally, your question addressing the issue of “when doctors refuse to listen to family members” is more difficult to answer.  In one hand I can tell you that most doctors I have met do listen to family but unfortunately because of confidentiality laws and rules are often unable to act or perform in a way that the family feels listened to.  You can also add the nature of this devastating illness that sometimes causes the consumer to confuse the situation and ‘split’ providers and family members in order to get their way.

I suggest to any family who is struggling with this particular issue to not give up, if you love your family member, then by all means keep contributing to the discussion with your loved one’s medical and clinical team.  It will make a difference. 

2) Question: Please help clear up information about marijuana and its addictive nature.  With so many states legalizing it, and so many TV hosts expounding on its value, there is great confusion about its addictiveness.  Professionals in our field need to speak up and talk about their experiences with clients who seek treatment for marijuana dependence, and some clear information about its addictive nature, and treatment, would be helpful.

Answer: It seems like every day more people support marijuana use, but they are frequently misinformed about the drug’s dangers and its addictive nature.  The myth that marijuana does not present the potential for being addictive, especially to adolescents and children, has been completely proven wrong by scientific research from around the world.

Here's what the National Institute on Drug Abuse (NIDA) says is known about the effects of the drug, a shredded green and brown mix of flowers, stems, seeds and leaves derived from the hemp plant Cannabis sativa.

NIDA says that marijuana's main psychoactive ingredient, tetrahydrocannabinol (THC), binds to cannabinoid (CB) receptors, widely distributed throughout the nervous system and other parts of the body. In the brain, CB receptors are found in high concentrations in areas that influence pleasure, memory, thought, concentration, sensory and time perception, appetite, pain and movement coordination.

That's why marijuana can have wide-ranging effects, including:

- Impaired short-term memory. Marijuana use can make it hard to learn and retain information, particularly complex tasks.

- Slowed reaction time and impaired motor coordination. It can throw off athletic performance, impair driving skills and increase risk of injuries.

- Altered judgment and decision making. Experts say this can contribute to high-risk sexual behaviors that could lead to the spread of sexually transmitted diseases.

- Increased heart rate. It can jump by 20% to 100%, which may increase the risk of heart attack, especially in otherwise vulnerable individuals.

- Altered mood. In some, marijuana can induce euphoria or calmness; in high doses it can cause anxiety and paranoia.

- The agency says long-term marijuana abuse can lead to:

     - Addiction.

     - Poorer educational outcomes, poorer job performance and diminished life satisfaction.

     - Respiratory problems (chronic cough, bronchitis).

     - Risk of psychosis in vulnerable individuals.

     - Cognitive impairment persisting beyond the time of intoxication

THC (Tetrahydrocannabinol), the active ingredient in marijuana, interrupts the natural process of endocannabinoids, a key family of chemicals that help guide the brain in proper maturation and play key roles in memory formation, learning, decision-making.

Not everyone who uses marijuana regularly experiences problems with thinking and memory, but researchers have not been able to predict which users will and which won't.

NIDA reports that one-third of Americans have tried marijuana at least once, making it the most commonly used illegal drug in the United States — and a prime target for research. NIDA estimates that about 9 percent of frequent marijuana users are dependent on the drug.

The good feeling reported from using marihuana is tied to the dopamine-based reward system in the brain’s nucleus accumbens region. Compounds in marijuana bind to the brain’s cannabinoid receptors, triggering dopamine release and resulting in a high. Long-term use of marijuana not only increases the amount of the drug that users need to reach the same high, it also inhibits the brain’s natural cannabinoids. As a result, over time users feel dysphoric and “off” if they haven’t recently taken marijuana. Marijuana also targets and interferes with cannabinoid receptors in areas of the brain crucial to a number of cognitive functions, especially the cerebellum (movement), hippocampus (memory) and amygdala (emotional control).

It is the interference with those cognitive processes that is particularly dangerous for young people’s developing brains and there’s evidence to suggest using marijuana at an early age can have lifetime consequences. Twin studies show that people exposed to marijuana as young teens are more likely to become dependent on other drugs, such as cocaine and painkillers (NIDA).

A recent NIDA report also shows that for the first time since the late 1970s, more 12th-graders are smoking marijuana than cigarettes — and marijuana is much stronger today than it was back then.

In explaining  Marijuana's Addictive Potential, the California Society of Addiction Medicine state that there are four separate lines of research that prove marijuana has all the characteristics of an addictive drug.

- Neuroscientists have demonstrated that marijuana affects the brain's Reward Center in exactly the same way as all other known drugs of addiction.

- Animal studies have demonstrated consistent patterns of behavior when THC, the main active ingredient in marijuana, is given twice a day for one week and then suddenly withdrawn

- Clinical reports of humans reveal a similar pattern of withdrawal symptoms during the first weeks of abstinence, including

     - Common symptoms

          - Decreased appetite or weight loss

          - Irritability

          - Nervousness/anxiety

          - Restlessness

          - Sleep difficulties, including strange dreams and EEG changes

     - Less common symptoms/equivocal symptoms

          - Chills

          - Depressed mood

          - Stomach pain

          - Shakiness

          - Sweating

          - Anger or aggression

- Epidemiologists have found that ~9% of people who begin smoking marijuana at 18 years or older satisfy the criteria for dependence. This number triples at ages under 18. The rate of dependence among near daily users is estimated to be 35-40% for dependence at some time in their lives.

More than 29 million Americans reported using marijuana in 2010 and daily use increases the risk of becoming dependent.

There are positive effects of marijuana use that include helping people relax and interact with others. It also can enhance some sensory experiences, such as listening to music. And consumption for medical purposes can reduce symptoms of disease and treatments of disease.

Dependence, on the other hand, can cause impairment or distress that interfere with other areas of life such as the ability to think clearly, to remember, to organize thoughts, and to follow through with multitasking.

More than 29 million Americans ages 12 and older — 11.5% — reported using marijuana within the past year, according to NIDA numbers for 2010. That's a significant increase over numbers reported each year from 2002 to 2008.

More research is needed on how marijuana affects people of different ages and background. There is evidence of genetic vulnerability to dependence but it is still at an early stage of being studied. And certain health conditions also put people at higher risk of problems, for example, people with cardiovascular disease will be at increased risk of a heart attack.

3) Question: What effect does alcohol have on a pre-pubescent boy, such as health problems, effects on the neurotransmitters in the brain, etc.?

Answer: Alcohol affects brain chemistry by altering levels of neurotransmitters. Neurotransmitters are chemical messengers that transmit the signals throughout the body that control thought processes, behavior and emotion. Neurotransmitters are either excitatory, meaning that they stimulate brain electrical activity, or inhibitory, meaning that they decrease brain electrical activity. Alcohol increases the effects of the inhibitory neurotransmitter GABA in the brain. GABA causes the sluggish movements and slurred speech that often occur in alcoholics. At the same time, alcohol inhibits the excitatory neurotransmitter glutamate. Suppressing this stimulant results in a similar type of physiological slowdown. In addition to increasing the GABA and decreasing the glutamate in the brain, alcohol increases the amount of the chemical dopamine in the brain's reward center, which creates the feeling of pleasure that occurs when someone takes a drink.

Alcohol affects the different regions of the brain in different ways:

Cerebral cortex: In this region, where thought processing and consciousness are centered, alcohol depresses the behavioral inhibitory centers, making the person less inhibited; it slows down the processing of information from the eyes, ears, mouth and other senses; and it inhibits the thought processes, making it difficult to think clearly.

Cerebellum: Alcohol affects this center of movement and balance, resulting in the staggering, off-balance swagger we associate with the so-called "falling-down drunk."

Hypothalamus and pituitary: The hypothalamus and pituitary coordinate automatic brain functions and hormone release. Alcohol depresses nerve centers in the hypothalamus that control sexual arousal and performance. Although sexual urge may increase, sexual performance decreases.

Medulla: This area of the brain handles such automatic functions as breathing, consciousness and body temperature. By acting on the medulla, alcohol induces sleepiness. It can also slow breathing and lower body temperature, which can be life threatening.

In the short term, alcohol can cause blackouts -- short-term memory lapses in which people forget what occurred over entire stretches of time. The long-term effects on the brain can be even more damaging.

Long-term drinking can leave permanent damage, causing the brain to shrink and leading to ­deficiencies in the fibers that carry information between brain cells. Many alcoholics develop a condition called Wernicke-Korsakoff syndrome, which is caused by a deficiency of thiamine (a B vitamin). This deficiency occurs because alcohol interferes with the way the body absorbs B vitamins. People with Wernicke-Korsakoff syndrome experience mental confusion and lack of coordination, and they may also have memory and learning problems.

The body responds to the continual introduction of alcohol by coming to rely on it. This dependence causes long-term, debilitating changes in brain chemistry. The brain accommodates for the regular presence of alcohol by altering neurotransmitter production. But when the person stops or dramatically reduces his or her drinking, within 24 to 72 hours the brain goes into what is known as withdrawal as it tries to readjust its chemistry. Symptoms of withdrawal include disorientation, hallucinations, delirium tremens (DTs), nausea, sweating and seizures.

4) Question: My seven year old son has been acting out/being aggressive at school with the other children and ‘acting weird’ with them, to the point where no one wants to talk to or play with him. His father (we are in the midst of a divorce) has Asperger’s syndrome and I assumed my son did also. However, when we had him tested, the tests came back negative for Asperger’s and autism. What other mental disorders might be indicated by his behavior, or, what else is he at risk for, and what can I do for him? Are there other screenings that might be useful in this situation? I want my son to have a good experience at school, and socially, and to be healthy, but I’m not sure where to turn to next.

Answer: Children misbehave for a variety of different reasons. Perhaps they don't understand the rules, they feel they need to assert their own autonomy, or maybe they wish to test the limits imposed on them. However, some children misbehave because they are experiencing internal distress: anger, frustration, disappointment, anxiety, or sorrow. The younger a child is, the more likely he is to call attention to his distress through his behavior. As a child matures, however, there is an expectation that he will be increasingly able to resolve much of his distress on his own and will express his feelings through words rather than outwardly directed misbehavior.

There are also children, however, whose behavior is consistently troubling to others. In these cases, the children's behaviors are outside of the range of what is considered normal or acceptable for their level of development. Perhaps most alarming is that many of these children show little remorse, guilt, or understanding of the damage and the pain inflicted by their behavior.

Some studies report that high levels of activity and unmanageable behaviors at the age of four anticipate behavioral problems in later school years. This is the best time to intervene.

Behavioral problems at eight are reliable predictors of adolescent aggression. Many of the underlying causes of childhood behavioral problems, including family violence and abuse, and even family history of illness, can be prevented or successfully managed. It's important to look beyond obvious negative behaviors to identify underlying biological, emotional, or social vulnerabilities that might be present and treatable.

Children's temperaments vary and thus they are quite different in their ability to cope with stress and daily hassles. Some are easygoing by nature and adjust easily to events and new situations. Others are thrown off balance by changes in their lives.

Some of the diagnosis that include aggression as a symptom include: Oppositional defiant disorder; Attention deficit hyperactivity disorder; Depression ; Bipolar disorder and Hyperactivity disorder among others.

Children who are physically and verbally aggressive much of the time should be evaluated to determine the proper diagnosis. In cases of severe aggression the diagnosis may be Conduct Disorder in which case their aggression typically is expressed toward people and animals, in the destruction of property, in lying and theft, and in serious violation of society's rules.

Conduct disorder is the most frequently diagnosed childhood disorder in outpatient and inpatient mental health facilities. It is estimated that 6 percent of all children have some form of conduct disorder, which is far more common in boys then in girls.

In order to diagnose conduct disorders, a clinician will look for a repetitive and persistent pattern of behavior which violates the basic rights of others. Usually, a child with a serious conduct disorder will engage in a number of unacceptable activities and seems to lack empathy and have little or no remorse, awareness, or concern that what he is doing is wrong.

For example, children with conduct disorders might bully, threaten, and intimidate others. Typically, they initiate physical fights, sometimes using weapons such as bats, bricks, broken bottles, knives, and guns. These are the children and, later, the adolescents and adults who get involved in muggings, purse snatching, armed robbery, sexual assault, animal torture, and rape. Some children deliberately set fires, vandalize, and destroy others' property.

In many instances, unrecognized and untreated learning disabilities and cognitive deficits create deep frustration for a child. Thus the entire school experience gets filtered through defeat and humiliation. A child may then stop attending school or skip challenging classes. Once he leaves the structure of school which might have been a major opportunity he had for experiencing positive success, he my engage in delinquent behavior. For some children, delinquent behavior, however unlawful or unacceptable, provides them with both the status among their peers and the opportunity for some reinforcement that they are unable to find at school.

More and more, child psychiatrists and other mental health professionals are recognizing the role played by prior physical, sexual, and emotional abuse in the genesis of certain kinds of aggressive and inappropriate sexual behaviors. Substance abuse or mental illness in parents psychosis, severe depression, or manic depressive di

sorders can have a grave impact on the children in the family.
High rates of family instability, social disorganization, infant morbidity and mortality, and severe mental illness are factors that may well cause and perpetuate severe conduct disturbances in a child.

Substance abuse and conduct disorders commonly coexist in a child or teen. It is not unusual for deeply troubled children, some eleven or twelve or younger, to use drugs and alcohol. Children use drugs and alcohol for a number of reasons. They may try to self-medicate for anxiety, depression, thought disorders, and hyperactivity. They may wish to blot out memories of abuse or treat insomnia. Some children think they need drugs or alcohol just to be able to face another day in a violent, abusive household.

5) Question: Are there online mental health screenings for youth that they can do themselves, and then get free, easily accessible information on their scores? Are there websites aimed at youth with these kinds of tools and information, and if so, what are they?

Answer: There are online mental screenings that are self-administered, others are administered by clinicians.  But the important factor is not only the proper administration but the interpretation of the results.  Unless you have the knowledge to interpret the results properly you may be causing more harm than good.

For a comprehensive list of screening tools I suggest that you visit the SAMHSA-HRSA Center for Integrated Health Solutions Screening Tools page at

But I do not recommend that anyone attempt to self-diagnose a problem without the guidance and support of a behavioral health professional.   

6) Question: It seems that prevention is a family and community affair. But what can be done when both parents have problems that they are not addressing, such as alcoholism for one and an undiagnosed mental disorder for the other, and they are divorced and their poor 6 year old is depressed and falling through the cracks? The urban school system doesn’t seem to notice or care, and you can’t talk to the parents. What can a concerned bystander do in such a situation?

Answer: Schools already have become the de facto provider of mental health services to children and adolescents, related to several barriers to accessing traditional community-based care, including lack of available specialists, insurance restrictions, appointment delays and mental health stigma (Committee on School Health, 2004; Farmer, Burns, Philip, Angold, & Costello, 2003; New Freedom Commission on Mental Health, 2003; U.S. Department of Health and Human Services [DHHS], 1999). In fact of children who do receive mental health services, 70% to 80% of them receive those services in schools (Rones & Hoagwood, 2000; Farmer et al., 2003).

The good news is that the Patient Protection and Affordable Care Act (ACA), signed into law on March 23, 2010 (P.L. 111-148) includes a provision that authorizes funding to establish and expand school-based health centers, which will significantly increase and enhance access to mental health services in schools.

Implementation of the Patient Protection and Affordable Care Act (ACA) is well under way, creating long-overdue opportunities for growing the capacity of child and adolescent mental health systems and meeting children’s pressing needs. The good news is that as of January 1, 2014, coverage of mental health conditions and substance use disorders will be required as part of the broad Essential Benefits package of services under the ACA. While states will determine specific benefits, it is widely accepted that mental health and substance abuse coverage will substantially increase, though the details remain to be determined. Additionally, as a result of this new law, funding for prevention, early intervention, and treatment services and programs will likely expand.

According to the Children’s Health Insurance Reauthorization Act of 2009, a School-Based Health Center (SBHC) is defined as “a health clinic that is (a) located in or near a school facility of a school district or board or of an Indian tribe or tribal organization; (b) organized through school, community, and health provider relationships; (c) administered by a sponsoring facility; (d) provides thorough health services to children in accordance with state and local law, including laws relating to licensure and certification; and (e) satisfies such other requirement as a State may establish for the operation of such a clinic.” The majority of these clinics are located in high needs areas, with large populations of vulnerable and often underserved youth, further underscoring the importance of the additional funding provided under ACA. Research indicates that 75% of SBHCs have a mental health provider on staff (Strozer, Juszczak, & Ammerman, 2010). Further, mental health care is the number one reason students visit SBHCs with the most common services being crisis intervention, mental health assessment and referrals, screening, and brief therapy (Strozer et al., 2010; Wasczak & Neidell, 1991). A promising provision of ACA to school mental health professionals is the authorization of funding for SBHCs in schools across the United States. In July 2011 the Health Resources and Services Administration (HRSA) put out a press release announcing $95 million of award funding to 278 SBHC programs across the country. These funds were made available under the ACA with the aim of expanding and providing quality health care services in a school setting throughout the nation. Specifically, this award enables SBHCs, who currently serve approximately 790,000 children and adolescents, to increase their capacity by over 50% to serve an additional 440,000 patient (U.S. DHHS, 2011c). As these funds are allocated towards construction, renovation and equipment, this money will go towards establishing new sites and/or upgrading existing SBHCs.

With schools serving as a key provider of primary care services, this funding can aid in increasing the number of students able to access health and mental health services. While not an immediate solution to the need to improve access to high quality health care in itself, increasing the number of SBHC facilities is a step in the right direction towards the ultimate goal of increasing school mental health and health care service provision to students and their families.

A challenge to capitalizing on the ACA opportunity, however, is the underdeveloped state of children’s mental health services across the United States. Unlike children’s physical health services, for which there is a robust private and publicly funded functioning system, management and delivery of mental health services are much less well developed or coherent. From significant disconnects between the multiple institutions that serve children and their families, to chronic financial instability, the children's mental health system is fragile and at-risk. Realizing the promise of the ACA for children and adolescents will require acknowledging systemic barriers that often lead to significant disparity and gaps in care.

This research, conducted by the George Washington University Center for Health and Health in Schools (CHHCS), identifies the systemic challenges to ensuring children’s access to mental health care common among many states, and points to encouraging examples of success. The bright spots can serve as a guide for those responsible for implementing the ACA or developing other policies that strengthen children’s mental health supports. 

The report can be found at

External link. Please review our Disclaimer