In an analysis of nearly 12,000 American children, researchers found that about half of those children with mental health-related distress or at elevated risk of emotional and behavioral problems had no active clinical contact with behavioral health services — and young Black children were especially underserved.

In the study, published March 15 in JAMA Network Open, the authors relied on a nationally representative sample of children from three separate National Surveys of Children's Exposures to Violence, which were carried out in 2008, 2011, and 2014, respectively. In those surveys, interviewers spoke over the phone to children or, if the children were under 10 years old, their parents. The authors of this particular study identified children with mental health distress symptoms such as anxiety, anger, depression, dissociation and post-traumatic stress. They also tracked how many adverse childhood experiences, or ACEs, the children had experienced. ACEs include events such as parental drug use, sexual abuse and exposure to domestic violence.

"Adverse childhood experiences are strongly associated with poor health and social problem outcomes later in life, including all kinds of chronic diseases," David Finkelhor, a professor of sociology and the director of the Crimes Against Children Research Center at the University of New Hampshire and lead author of the article, told The Academic Times. 

"There are a lot of questions about how to translate that particular insight into effective public policy. One of the questions that needs to be understood for making good policy is, how much of this high-risk population is actually already in a position where they're getting some services? How many are at least on the radar screen of people who are providing services for behavioral health disorders?" Finkelhor said. "Almost everybody assumes that large portions of that at-risk population are not being served, but delineating what the exact proportions are is important to the argument for more services and better-targeted services."

A troublingly large proportion of young children and adolescents who were at risk or actively suffering distress had no clinical contact. For example, 57% of children ages 2 to 9 with a heavy burden of ACEs did not have any clinical contact. The percentage increased to 63% of the high ACE group among children ages 10 to 17. In both age groups, more than half of children with mental health distress symptoms had apparently slipped through the cracks. And in the younger age group, Black children with high ACEs were only 25% as likely to have that clinical contact as non-Hispanic white children with high ACEs.

"I expected kids who were displaying symptoms would be more likely to be receiving services, but there wasn't a strong indication of that," he added. "I frankly don't know why."

Finkelhor believes that children with active mental health symptoms should be more of a focus for behavioral health professionals than those with ACEs. After all, while ACEs are a risk factor for social and psychological problems, many children who experience them may develop healthy coping strategies.

"It's also easier to figure out what to do," he said. "If a kid is depressed, we have depression treatments. If a kid is anxious, we have anxiety treatments. When you just have a kid who's been sexually abused or a kid who's been physically abused or bullied, there's no generic treatment for that."

There is also a debate among sociologists, psychologists and other researchers as to whether poverty itself should be classified as an ACE. "Poverty affects children in some way," Finkelhor explained. "It makes their parents less available. It gives them fewer educational opportunities for enrichment. It may put stresses on the family that result in them being treated more harshly by their parents. They may feel deprived. The question is whether you can measure these other things and get a better assessment of risk than simply not having sufficient money. But some people think that poverty is a particularly good way of summarizing the risk. I actually think poverty should be counted, but the original ACE research, which was done primarily by psychiatrists and pediatricians, didn't count that."

The authors of the study theorized that systemic racism could be responsible for the substantially lower behavioral health contacts among Black children. In almost all of the high-risk groups, Hispanic children and those in the "Other" category, which embraces Alaska Native, American Indian, Asian or mixed-race individuals, also reported lower contact than comparable non-Hispanic white children.

"The problem is cultural specificity," Finkelhor said. "People need providers who understand their background, who the kids in their families are comfortable with. We've got to train up more people who come from those backgrounds to provide those services. Making sure that the services are available in the environments seems to me to be the top priority."

Finkelhor acknowledged that the study's reliance on self-report could be a disadvantage. "Some of it is based on recall, which can be a problem," he added. "You can't expect a 14-year-old kid to really tell us accurately what happened to them when they were 3 years old."

The sample also included a disproportionately high percentage of parents with a graduate school education, as well as a disproportionately low percentage with only a high school education. "We used weights to make it correspond to the profile of the country as a whole," he explained. "That could have taken care of the overrepresentation."

Finkelhor is most interested in ensuring that kids who need services have access to them. "I think that one of the best policy suggestions in this area is to make services more readily available in schools and medical practices — places where kids are already going and are already somewhat comfortable," he said. "We have to increase the number of providers and payments to providers. Reimbursements to people in this segment of the health care system are very low, and there really is a lack of people who are going into this field."

"The thing that we really haven't addressed, that needs to be addressed by other research, is, what are the barriers to service?" Finkelhor said. "Is it that the kids in the families are averse to the idea of getting [services] because they think they're stigmatizing, or they don't think they'll be helpful? Are they too difficult to access? Do they require somebody taking off time from work or interrupting a kid's activities to take them somewhere? Are there just long wait times or no services in the area? And when they do go, are they referred to services that we know are effective?"

He added, "There's a big untreated need here because the policymakers aren't given a lot of guidance about what to do."

The study, "Receipt of Behavioral Health Services Among US Children and Youth With Adverse Childhood Experiences or Mental Health Symptoms," published March 15 in JAMA Network Open, was authored by David Finkelhor, Heather Turner, and Deirdre LaSelva, University of New Hampshire.