By Matthew G. Biel, Michael H. Tang, Barry Zuckerman, JAMA Pediatrics, April 6, 2020
Pediatric mental health (MH) concerns, including depression, anxiety, loneliness and social isolation, and suicide, have increased markedly in the last decade and are critical factors associated with population health. While effective interventions for these conditions have been developed and pediatric health care professionals increasingly address MH concerns as a central component of clinical practice, our health care systems have not met the challenge of providing evidence-based treatment to all young people who need it. Too many children never receive adequate MH assessment1 or timely intervention,2 and access to specialty MH clinicians is inadequate. In addition, the treatments that are delivered are often incomplete and ineffective, particularly for the most vulnerable children. The current state of care delivery must be improved to implement high-quality care more broadly and produce better outcomes.
As we attempt to bridge these gaps, we must remember the potent intergenerational nature of MH problems. Failure to address parent MH concerns may be an underrecognized and critical factor adversely affecting efforts to effectively treat pediatric MH problems. The emergence of MH concerns during childhood represents the combined effect of genetic risk as conditions such as depression, anxiety, and attention-deficit/hyperactivity disorder are highly heritable, as well as lived environmental risk through exposure to adversity that is often mediated by children's relationships with their parents and caregivers. Attention to adverse childhood experiences (ACEs) and trauma has highlighted how the experience of adversity in the home and community plays a powerful role in shaping brain development and health. Having a parent with untreated mental illness or addiction is a formidable adverse childhood experience that shapes a child's lifelong developmental trajectory through multiple mechanisms, including genetic risk, epigenetic modifications, behavioral modeling, social learning, and relational skills.3 Adversities associated with unaddressed MH problems and relational difficulties within families have a crucial association with efforts to effectively support pediatric MH. Pediatricians are being encouraged to elicit 3-generation family histories of mental illness to identify risk, promote resilience, and reduce intergenerational transmission through referral for MH services and other supports.4 Screening and referrals are critical first steps. We also need to examine clinical care delivery models within child-serving health and MH care settings to promote intergenerational approaches that may generate improved outcomes for parents and children.