What Have I Done?

August 22, 2023

… You may ask yourself, “What is that beautiful house?”

You may ask yourself, “Where does that highway go to?”

And you may ask yourself, “Am I right, am I wrong?”

And you may say to yourself, “My God, what have I done?”

Talking Heads, “Once in a Lifetime”

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I’m looking back, trying to judge what I accomplished in my career. My career is far from the only thing that matters in reflecting on my life, but it matters. This is my question:

Did I accomplish anything in 50 years of work in child and youth mental health?

I graduated from college in 1976 without any idea what I would do with my life. I found a minimum-wage job working as a therapeutic childcare worker. That is, I took care of children institutionalized with severe mental illnesses. It’s challenging work.

The psychiatrists and psychologists who supervised us had theories about what kinds of care would make the kids healthier. None of their theories worked, in part because they never tested them in experiments. I found my calling when I realized that the doctors running the clinics where I worked didn’t know what they were doing.

I went to graduate school and became a child psychologist and a statistician. My mission was to work on developing a scientific approach to mental health care that would help kids and their families.

Now it’s 2023, 47 years later, and I am near the end of my life. What did I accomplish? Let’s break that into two questions. First, did I contribute to the sciences devoted to child and youth mental health care? Second, have those sciences improved child and youth mental health?

Reflecting on mortality with Mika. I had recently been told that I had less than a year to live. (That was two years ago!)

On the first question, my answer is,

“Yes, I made some contributions.”

I conducted studies and published papers in developmental psychology, applied statistics, mental health epidemiology, and child mental health services research. Other researchers have cited some of my articles many times, suggesting that my research helped them carry out their work. Many pediatricians and family physicians use a mental health screening tool I developed. I’ve received academic tenure and have been promoted to Full Professor. I’m not famous, but honestly, that was never my goal, and it means nothing to me now. I wanted to put my shoulder to the wheel with other scientists and help move the field. I accomplished that.

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But the second question matters more:

Have we improved children’s lives? Is the mental health of children and adolescents better than when I started?

One of the frustrating things about working in mental health is that in 2023 we cannot credibly answer whether children have better mental health than in 1976 or in 2022.

Compare the situation of child mental health researchers to economists. Economists can say, with some precision, whether people’s economic circumstances have improved from year to year. They know how to measure employment, income, and wealth. Similarly, epidemiologists can measure population health for many diseases, including cancer.

But we haven’t been able to quantify the population’s mental health, so any judgments about whether it has improved or worse will be subjective opinions. And few people believe children and adolescents have better mental health today than previous generations.

My answer, then, is

“No. Even though I have contributed to the relevant sciences, I’m not confident we improved child and adolescent mental health.”

Which is just terrible.

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If that answer is correct, why have we made so little progress?

We have made some things better, but not enough to matter. Here is a simple model for what we need to accomplish to improve population health.

(1)   We need effective methods to prevent children from developing mental health disorders and effective treatments for when they do. To develop effective preventive and treatment interventions, you need rigorous scientific methods. You might imagine that “science is science,” but that’s untrue. The ‘research’ that influenced child mental health care in 1976 comprised case studies selectively published by psychoanalytic charlatans. My view is that we have made considerable progress in research methods. Unfortunately, even the best mental health treatments are only moderately effective. Moreover, there have been few, if any, breakthrough treatments in the last 20 years.

(2)   We need mental health care systems that successfully deliver effective treatments and these interventions to the populations and individuals who need them. An excellent treatment won’t benefit anyone if it remains on the shelf. We have a few effective treatments for mental illnesses. Unfortunately, we do a poor job of getting them to the people who need them. The most important thing to know about the epidemiology of mental health problems is that disorders are most common and most severe among those at the bottom of the social order. The most important thing to know about who receives mental health treatments is that they primarily go to affluent and well-educated people. I’m sure you see the problem.

(3)   Now, suppose that we not only have effective treatments, but we also have high-quality mental health treatment systems that will efficiently deliver them. We still need to mobilize the public to pay for these treatments. I do not think society spends enough on mental health care; for example, insurance plans do not provide adequate mental health coverage.

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Here’s why improving population mental health is complex. You must succeed at all three tasks to improve population health. Making a little progress in just one domain accomplishes nothing. For example, developing a breakthrough treatment won’t materially improve population health if society isn’t willing to pay for the treatment and the healthcare system can’t or won’t deliver it. Looking back over the past 47 years, we’ve made a small amount of progress on (1), (2), and (3). But the minor effects aren’t additive. Instead, our shortfall on each point helps suppress the effect of the other two on population mental health. As a result, we haven’t improved population child and adolescent mental health

Bill and Mika, at peace with how things worked out.

.How, then, do I feel about my career? I gave it my best shot, meaning that I and many others sought the truth using science, but we didn’t accomplish much for children and their families. Perhaps we have laid some foundations on which future generations can build.