Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 13 - Evidence for May 1, 2003


OTTAWA, Thursday, May 1, 2003

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 11:05 a.m. to study on issues arising from, and developments since, the tabling of its final report on the state of the health care system in Canada in October 2002. In particular, the committee shall be authorized to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: To our witnesses in Vancouver, thank you very much for getting up early to be with us.

Honourable senators, we have a distinguished group of witnesses with us this morning. We will ask Dr. Waddell to begin.

Dr. Charlotte Waddell, Assistant Professor, Mental Health Evaluation and Community Consultation Unit, Department of Psychiatry, Faculty of Medicine, University of British Columbia: Honourable senators, we will use overheads to explain our presentation this morning. Improving the health of Canadian children is the goal that interests all of us when we discuss the topic of childhood mental disorders.

By way of introduction, most of us who work with children and/or who are concerned with children's policies agree that, in healthy communities, it is the responsibility of everyone and in the interest of everyone to ensure that all children thrive. Optimal mental health and development are core features that are necessary for children to thrive.

In the current state of children's mental health, despite making good progress in recent years with regard to research, treatment and prevention, the burden of suffering associated with children's mental disorders remains high. About 14 per cent of Canadian children — about 1 in 7 — have clinically significant mental disorders severe enough to cause distress, but also to impair their functioning in various spheres — at home, at school and in the community.

The first overhead shows prevalence data summarized from recent international surveys looking at Canadian data from Ontario and Quebec, but also data from the U.S. and the U.K.

The numbers are not as important as noting the order of prevalence. The top four disorders are anxiety, attention, conduct and depressive disorders. In overall prevalence rates, based on our best currently available research evidence, about 14 per cent of children are severely affected by mental disorders. In Canada, that translates into approximately 1.1 million children. Of those children, approximately half have two or more disorders concurrently. The burden of suffering is in some ways under-represented by those simple numbers.

What are we doing currently in terms of services and programs for these children? We have basic data also from epidemiology surveys. That data shows less than a quarter of the affected children are receiving specialized mental health services. About half do receive primary care or school-based services for their mental health problems.

Given the high numbers, we are left with a real conundrum. How do we address the suffering of these 14 per cent, over 1 million children? It is unlikely that continuing to invest solely in clinical treatment services will meet their needs. Training and recruitment issues alone make this not feasible. We suggest instead that a broader population-health approach is needed in addition to clinical treatment services. The next diagram illustrates what we mean by a broad population-health approach.

The largest oval in the diagram represents, if you will, the universe of all children in Canada. A broad population- health approach suggests that we turn our attention to how are all children doing and that we promote mental health for all children. Moving to the second oval, we need to prevent disorders in children who are at risk. Finally, in the smallest oval, we must look at treatment for children who have established disorders, being the 14 per cent we have mentioned. They are the most severely affected.

The first basic component of the population-health approach is promotion. How are we doing in that regard? Overall, Canada has made limited ``upstream'' investments in promoting mental health and preventing disorders. Most of our resources are still directed ``downstream,'' at clinical treatment services, after disorders are already established.

Most of our current focus in health promotion is on early childhood development. That is a very important focus. Many people are enthusiastic about this focus and we look forward to seeing positive results from it.

However, this kind of early childhood development focus to date has not specifically included mental health, and early childhood development initiatives have yet to be fully evaluated, particularly with regard to mental health outcomes.

Turning to prevention, that second part of the overall population-health diagram, there is positive news with regard to emerging research evidence that there are approaches that work well to prevent some of the leading children's mental disorders: anxiety, conduct and depression, for instance. For anxiety disorders, excellent evidence is emerging from Australia that school-based, classroom-wide, common cognitive-behaviourally-based programs managed by teachers can improve social skills for all children, but can significantly reduce anxiety in children at risk. For conduct disorder, another severe and quite different kind of disorder, excellent evidence has emerged from the United States regarding nurse-home visitation and the ability of programs that involve support to high-risk parents, starting in the prenatal period and following through for two years or so, to significantly reduce child abuse and neglect as well as conduct disorder 15 or 18 years later.

Despite this growing evidence with regard to effective prevention approaches, we do not currently in Canada, at the national or any provincial level, fund or support significant prevention programs that focus on these mental disorders.

We also need more research on prevention. Many of the trials that have been done have been conducted in the United States or Australia. Some of those results are highly generalizable. Some need to be replicated in Canada.

Our recommendations, then, regarding promoting health and preventing disorders are: to evaluate early child development initiatives, particularly with regard to mental health outcomes; to establish prevention programs based on the current research evidence — and anxiety, conduct and depression would be good disorders with which to start; and to encourage more Canadian research to replicate some of the strong findings coming from other places.

Moving on to what would be the inner circle on that population-health diagram that we showed you earlier, what about providing effective treatment services for those who have disorders? The positive news here is that effective treatments do exist for many of the most common disorders, again including anxiety, attention, conduct and depression. For instance, for anxiety disorders, cognitive-behavioural approaches are very effective. For conduct disorder, approaches that teach parents and schools and work with them to use more constructive approaches with children are effective. For attention deficit, there are some effective pharmacological interventions. These treatments can reduce distress and impairments associated with disorders. However, most children with mental disorders are actually not receiving these effective treatments. We have a large problem here, and we need to look carefully at why this is. If you recall, we said that only about 25 per cent of children with disorders receive specialized mental health services. We feel that probably treatments currently offered are not always based on the research evidence. In other words, practitioners are still using unproven treatments. That might be in specialized settings, and it might also be in primary care and schools.

We also believe that there are service delivery issues that partly contribute to this large gap and unmet need of children. There is emerging evidence about service delivery models that suggests that community-based programs involving primary care and schools are very effective, and probably more so than hospital-based or long-term residential programs when compared directly. The primary care and school programs have not been significantly funded overall and continue to be regarded as somewhat experimental. These two settings, primary care and schools, show the most promise, frankly, for identifying children in need and for actually reaching the majority of children. If children do not go to specialized services, they do nevertheless usually go to primary care or school settings.

Another overarching issue affecting this gap or unmet need involves the fact that children's services are fragmented. There are many jurisdictions, sectors and disciplines involved, not just federal, provincial, regional kinds of divisions, but also completely different sectors within provinces. Health, social services, education, justice and child protection may all be involved. There are many different disciplines involved as well. Better coordination is urgently needed because of this excessive fragmentation. In British Columbia, for instance, children's mental health services are delivered by at least three different major ministries, and two different levels of government are significantly involved. We are struggling to try to coordinate at a basic level.

What would we recommend with regard to these treatment service issues? First, we would recommend establishing evidence-based practice as the standard of care for delivering individual treatments, but also for designing health service delivery models. We would also suggest supporting effective community-based approaches, particularly primary care and schools. We would suggest coordinating services.

There is another element that is a necessary part of any broad, comprehensive population approach to any sort of health problem — but it applies well to children's mental disorders — that involves the need to monitor outcomes, to constantly ask, ``Are we doing the right things and are we doing them correctly?'' Basic information is lacking in children's mental health with regard to even costs and outputs of clinical services, for instance. We do not know how many children we are seeing, how much money we are spending and what basic services are being delivered. More importantly, there is not yet monitoring of outcomes to ascertain whether the services and the interventions that we are providing are reducing the number of children affected and the impairments associated with disorders.

Outcome monitoring needs to include broad population-health indicators, including things like school completion, child protection and justice system involvement, and suicide rates. It also needs to probably include epidemiological surveys of incidence and prevalence of disorders. We have those kinds of surveys well underway in Quebec and Ontario at present. We need to extend that to other provinces.

We recommend, regarding monitoring outcomes, developing a coordinated information system to monitor costs and outputs of clinical treatment services for a start, because those consume the majority of services at present, but also monitoring mental health outcomes for all Canadian children, not just those attending services.

Finally, as a basic conclusion, it is not hard to get most of us to agree that investing in the health of children is a foundation for any nation's productivity and success. I think we would all feel strongly about that. What is not as clearly understood is that mental health problems constitute probably the most important health problems that Canadian children are currently facing. I say that based on the numbers of children involved, the level of impairment, which is severe, and also on the fact that these disorders get a foothold early in life and are not being currently effectively treated, such that they often persist and go on to impair adult functioning and output.

Children's mental health has been largely, if you will, neglected in Canadian public policy-making. Roy Romanow referred to mental health as the ``orphan child'' of the health care system. Children's mental health is the orphan child of the orphan child. We would conclude that national and provincial leadership is urgently needed to begin to champion this issue, to bring it to people's attention, and to begin to implement a broad population-health approach to try to reduce this burden of suffering.

Dr. Howard Steiger, Professor, Psychiatry Department, McGill University; Director, Eating Disorders Program, Douglas Hospital: Honourable senators, my particular concentration is eating disorders, so I will be focusing my comments on that in particular.

Just to give people a little orientation, we know that eating disorders are complex syndromes. They are characterized by intense preoccupations with eating, body image and weight control. Invariably, that also coincides with relatively pronounced problems of adjustment or concurrent problems of a psychiatric sort. It is unusual not to see sufferers also showing mood problems, depression, marked anxiety problems, symptoms of a compulsive, highly perfectionistic type, or problems with impulse regulation. We see people showing repeated suicidality, self-mutilative gestures, shoplifting and other indications of a problem with impulse control. Eating disorders are not just about eating, but really quite pervasively affect functioning, and in the process, do grievous damage to both children's and adults' social, vocational, psychological and medical adjustment. These disorders, of course, because of the implicated dietary distress, also have pervasive physiological or medical effects.

These are also disorders that affect an alarmingly large number of individuals. If you look at the highest risk group, young women 12 to 30 years of age, you can easily estimate that one per cent of them are suffering full-blown anorexia nervosa and probably around two per cent bulimia nervosa.

You could say that up to 10 per cent of this young female group are suffering significant problems around eating and body image sufficient to be distressing and damaging to their adjustment.

This is not to discount eating disorders that occur with older women, males and various other age groups. I will be talking about older groups as well. At one point, I want to try to urge the need to bridge barriers between adolescent and adult areas of expertise.

The Chairman: Let me just caution you. When I hear people say ``I will be talking about something eventually'' I want to ensure that you try to give us a reasonable executive summary rather than the entire paper. I want to make sure that we have sufficient time for questions.

Dr. Steiger: We must understand that eating disorders have a complex cause. They have biological, psychological and social causality. We understand them to represent an activation by social pressures towards thinness, the mania towards dieting, pre-existing psychological vulnerabilities related to self-esteem, self-definition, the sense of self-worth and self-control.

Also, increasingly, we have evidence to favour the idea of a biological substrate. Eating disorders emerge increasingly as having a genetic basis, as being transmitted within families. Some of the recent genetic work is starting to pin down certain genetic factors. You want to understand them as a collision between biological, psychological and social factors.

If there is this complex causality, treatment also tends to be complex. It is generally multi-modal, requiring interventions from various kinds of sources such as biological, which would be nutritional and rehabilitative ones, as well as pharmacological involvements and psychological treatments aimed at problems of self-image, self-definition and self-esteem from familial disturbances. Social intervention may also need to be included through group therapy.

Most well-established eating disorder programs, therefore, have to offer a wide range of therapeutic interventions drawing upon a range of technologies from medical, psychological and social fields. Also, proper treatment necessitates the ability to offer fully intensive in-patient treatments, day-hospital type treatments, intensive day programs or out-patient treatments, which would be less intensive. We are talking about a sophisticated range of therapeutic interventions.

We have a fair amount of empirical research looking at the outcome for eating disorders. Those suggest that these disorders are difficult to treat and have a complex but a heterogeneous outcome.

With adequate treatment, at least a third of people respond very well. In the short term, they seem to be showing relatively good recovery. There is another substantial subgroup, probably up to a third, for which the prognosis is more guarded, and the outcome is less favourable.

In terms of health care delivery, there is a need for specialization. We have enough empirical work to show that while the eating disorders respond with difficulty to treatment, they do respond best to well-principled, symptom- focused treatments. A well-informed practice is necessary.

Interestingly enough, in line with some of Dr. Waddell's comments, there are surveys that show that the modal treatment that is available in the community to people with eating disorders is not that which is best indicated according to practice standards or empirical evidence. We really must move towards an emphasis on establishing consensus about what kind of practice standards will be involved.

I would suggest that to achieve that we must develop coordinated, network-type efforts aimed at eating disorder sufferers. I would see that probably at provincial levels, although there is also a need for federal direction.

Coordinated efforts between centralized or ultra-centralized centres of excellence should be at the hub. At the ends of the spokes, there should be selected regional or local resources offering more frontline service. At the specialized end, you would have large-scale, supra-regional programs seeing the critical mass of people and able to offer highly intensive treatment for sufferers of severe eating disorders.

The critical mass idea is very important. This allows for experience with large numbers of sufferers and the development of real clinical expertise. It also promotes sophisticated clinical research and becomes a base for clinical teaching. I am advocating fully integrated clinical research and teaching activity.

That is fine in terms of the generation of expertise, but it does not bring it out into the communities where people are suffering eating disorders. We also have to see coordinated efforts to export expertise to the frontline. We must see clearly established consultative links and funding to allow for consultation and supervision of people training in the frontline.

We are doing some of that type of work with our local community service centres in Quebec and having some good experiences. Similar projects have been done in B.C. and Ontario.

That kind of training also allows those on the frontline to develop a greater expertise in the initial assessment of and early intervention with eating disorder sufferers. Simple, well-informed group therapy can sometimes be marvellously effective for those people. When it is not, those people need access to a more centralized program able to offer intensive care for severe cases.

Concurrent with that, and also in line with some of Dr. Waddell's comments, we must really emphasize prevention and health promotion, through public health programs, presumably. We need to develop community outreach that would be aimed at community services, schools, religious groups and other settings in which young people are being seen where we can hope to do some primary prevention. As well, there is some interesting and promising work in the eating disorders area suggesting the utility of primary prevention efforts.

I mentioned the need to strengthen links between programs for children, adolescents and adults. There are often administrative barriers to this kind of connection. It is important in all areas, especially with eating disorders.

Adult programs, curiously enough, are actually seeing the largest number of sufferers with eating disorders. There is a myth that eating disorders are concentrated in early adolescence. The largest group of sufferers is around the age of 28.

The adult programs are having the large-scale experience. The adolescent programs are well placed to do early intervention before chronic symptoms develop. We have to get these groups talking to each other and exchanging expertise, which is very rarely happening in all provinces, as far as I am aware.

Along with that comes a need to fund clinical research efforts. I am strongly committed to the idea of a fully integrated kind of clinical research activity. Research, in the end, translates into better patient care. It is the only way to ensure that people in all communities are receiving properly evaluated methods of care that have demonstrable effects. It is also the only way to ensure that patients receive the kind of cutting-edge, well-informed practice that it is their right to receive. The modal treatment that is being delivered will hopefully come into line with more established practice.

Along with any of the developments towards programs, I would strongly advocate for a clear component of research and exportation of expertise.

Dr. Simon Davidson, Chief of Psychiatry, Children's Hospital of Eastern Ontario: Honourable senators, congratulations on embarking on a really important initiative for Canadians in terms of quality of life and for Canada in terms of consolidating as productive a society as possible. The sooner we can address mental health issues and their natural history, the more productive our society can become.

My brief is divided into three sections: An outline of the problem and its extent, for which I have also included a case example to make it a little more real; an analysis of the problem; and a proposal of what the system could or might look like.

In this presentation, I will hit upon the major points in the first two sections and I will focus on the third. However, I urge you to review this document as a whole. I am very pleased to have had the previous two witnesses go before me because I would strongly concur with much of what they said. I have also included that in my brief, which allows me then to focus on slightly different areas.

From an epidemiological standpoint, I agree with Dr. Waddell, although I think her figures are a little optimistic, unless she is particularly focusing on the severely mentally ill. If you look at the full spectrum, mildly to severely mentally ill, the actual prevalence rates are a little higher. We know that prevalence of psychiatric illness increases with age; however, we are also noticing the age of onset decreasing with certain of the disorders such as mood and eating disorders.

I wanted to make a comment about the questions that this committee framed for us. I liked what Dr. Waddell said about the orphan of the orphan. I am worried that when you segregate different disorders, you may end up having the orphan of the orphan of the orphan. Furthermore, there are disorders that are not mentioned in the questions that are of high prevalence or severity as well. Mood and anxiety disorders in children, anxiety disorders in adolescence and psychotic disorders across the age span should be addressed. That is the last thing that I will say about any specific disorders and I will, rather, look at the picture as a whole.

In terms of service utilization, we know from the original work of the Ontario Child Health Study that only one out of six children or youth 4 to 16 years old with at least one psychiatric disorder had any kind of exposure to management of it in the previous six months. That study was conducted in 1986; the reporting was in 1987 and 1989. Much water has gone under the bridge since that time, even if prevalence rates have stayed the same. After talking with Dr. Offord, I believe that fewer than one out of six receives any kind of service whatever.

The services, as Dr. Waddell has said, are almost exclusively clinical. There is an enormous demand for service and the waiting lists are extremely long. I have included in my brief a similar continuum of mental health services to that with which Dr. Waddell has presented you. I also want to make certain that I mention that working with children, youth and their families, where there are mental illnesses, is not the same as interventions with adults. Generalization from adult approaches to children and youth would be an error. I have included a case vignette that also highlights what Dr. Waddell was saying about how fragmented the service sector is, how many agencies are involved in providing various types of care and how many ministries in different provinces are engaged in funding those agencies.

As I have already said, demand for service far outweighs available resources. Certainly, wherever we have gone in Eastern Ontario and asked communities what health services they require to which they do not have good access in their area, among the top three are always mental health services for children and youth. There are several physician issues that potentiate the problem. I will come to that a little later. The high demand for service is one of the problems that keep us focused on clinical program delivery and away from providing universal and targeted programming of the type that would address health promotion and mental illness prevention.

There are very few universal and/or targeted programs, and Dr. Waddell has addressed that. We hear often in all kinds of circles that our children and our youth are our future and, quite frankly, I pose the question: Is that just rhetoric or does it have meaning?

Just to move away from health for a minute, I really like a quote from Tennessee Williams: ``There comes a time when it is right to depart, even though the destination is uncertain.''

I have a proposal in respect of change. This orphan of an orphan definitely needs more money, but we do need to do many things differently as well. I think that funding for mental health services needs to at least be in line with funding for physical health problems. We need to consolidate mandated and protected funding and, above all, if there is only one thing I could say, whatever we end up with, we need to have an integrated and balanced system.

There are many principles, and you know those, so I will not go into detail. There is a full spectrum of services that we need to provide and, in terms of the clinical ones, they need to be coordinated, cost effective and integrated in a continuum ranging from community-based services all the way through to specialized mental health services. The interdisciplinary approach is absolutely key to optimizing care. I strongly join with Dr. Waddell in urging that the system be balanced among universal, targeted and clinical programs that enhance reach, so we reach more children and youth, and that potentiate the multiplier effect, so that access to mental health care is much easier across the whole continuum and with an outcome that more people realize their potential and we have a healthier workforce and society.

Research and program evaluation is critical, and Dr. Waddell has addressed that. I will take a minute to talk about education, which is a bit out of date. We need to talk about education for all professionals who are engaged in the interdisciplinary team providing the full continuum of service. We need to develop new curricula for teaching, using contemporary approaches. The old approaches have some good parts, so we need to retain those. However, they predominantly focus on clinical service delivery and not on the balance that Dr. Waddell and I have spoken about.

We need to also develop innovative and interesting methods of doing the teaching. I would also like to advocate what I call ``the golden triangle,'' and I do not mean that place in Thailand. The golden triangle for me is the service provision that we have talked about — the universal, targeted and clinical, and the education, research and program evaluation. The three must exist with an iterative relationship among them, where each informs or modifies the other two. We need to coordinate this through effective information systems.

For child and adolescent psychiatrists, many things are problematic. A child and adolescent psychiatrist first becomes a physician, then a psychiatrist and then a child and adolescent psychiatrist. At this time in Canada, we are in negative balance. I believe that we are training fewer child and adolescent psychiatrists per year than are retiring, and we were already in negative balance. Furthermore, there is a problem with attracting people to child and adolescent psychiatry. It takes longer than general psychiatry to get there, and for the rest of your life, you will earn significantly less. It is a very hard sell to get people into child and adolescent psychiatry.

There are many other issues that need to be addressed that I have not touched on: housing and supports for children and youth; a receptive school system where the school is the hub — and I agree with that concept, but would note that children and youth that do not make it to school for truancy or school refusal reasons are at even higher risk than children and youth who do; young offenders with mental illnesses. There is high co-morbidity of this population, so although they may have conduct disorders or antisocial personality disorders, there is a very high prevalence of other psychiatric illness and these people do attempt and complete suicide.

Transition from youth to adult services is extremely important; youth employment is important; and focusing on the impact of mental illness of children and youth on their families is also extremely important.

In conclusion, we must do it right. Changes are relatively permanent. Our public must live with whatever changes we make for a long time. Whatever is done, child and youth mental health services must be protected and mandated. We need to develop a strategy for child and youth mental health focusing on the best interests of our children, youth and families, involving the right people — leaving affiliations at the door — and emerging recommendations must have teeth.

I would reiterate what I said a few pages ago, about believing that our children and youth are our future; is that just rhetoric, or does it have meaning?

Dr. Diane Sacks, President-Elect, Canadian Paediatric Society: It is left to me to put a personal face on this issue that my esteemed colleagues have talked to you about this morning. I will put on the best face I can for the children that I am honoured to represent, as well as for the other frontline workers or ``soldiers,'' as we sometimes feel after a long day in the office with these children, and let you know what is really happening out there.

It was only about 20 or 25 years ago that psychosocial dysfunction was first recognized in children. Today, it is the leading cause of disability in children and adolescents. A full 20 per cent of Canadians under the age of 19 suffer with one or more of these conditions to a moderate or severe degree. I do not mean mild, I am talking about they are not functioning — a full 20 per cent.

For 30 years I practised pediatrics and adolescent health at the Hospital for Sick Children. Seven years ago, I went to North York General Hospital, a community hospital. In addition, I have a private pediatric practice in North York.

I wish to describe a few of the disorders and explain how they impact on these young people's lives, their families and Canadian society in general.

Many of us are familiar with the idea of a critical developmental stage in the first three years of life, but fewer appreciate that there is a second such critical and crucial developmental stage that is equally important if we are to function independently and productively as individuals in a democratic system.

It is during adolescence that we face enormous tasks in psychosocial and physical development — tasks that define who we are as adults, tasks such as accepting our own strengths and weaknesses, accepting who we are with respect to our bodies, formulating cohesive relationships with those outside our family, such as a peer group, and separating from our families.

Not being able to accomplish these tasks stops the progress toward adulthood. Having a mental illness inexorably gets in the way of this progress. In many cases, it stops it dead in its tracks.

As you will see, significant numbers of teens are affected by mental illness, few get diagnosed and still fewer receive treatment, even after diagnosis. Recent knowledge from neurophysiology tells us that at this stage the brain is still flexible and plasticity exists.

Gains in treatment made at this stage should be even more effective than treatments instituted later on. Yet our health care system does not currently provide anywhere near adequate treatment for mental health for children and youth. More upsetting is that this treatment is not found in an equitable or accessible fashion as defined in the Canada Health Act. It is a waste of potential.

As might be expected in this area, all the incidence figures I will note are underestimates. I suspect that each one of you will be familiar in some way with the children and youth that I hope to describe.

About 5 per cent of our young people suffer from a condition pediatricians recognize as a huge mental health problem: ADD, ADHD and learning disabilities. As many of these children are bright, they can successfully go through the first six to eight grades masking their difficulties, and then comes junior high, high school and rotations and things begin to fall apart.

Many teens who have not been identified as having ADD or ADHD now begin to fail. They fail at a time when, for many, they feel that their bodies are also failing them. They are not strong enough, thin enough or definitely not tall enough. The pressures are enormous. Poor social skills, which go along with this condition, now cause rejection and peer conflicts. How can a failing, ``dummy'' teen with poor social skills, which is what untreated ADHD looks like, form the peer group we talked about as one the essential tasks of adolescence? He cannot. Self-esteem issues arise. This is directly related to acting out, bullying and problems with the law.

There is a rumour that if you give these children stimulants, they have a tendency to go on to substance abuse. Just the opposite is true. Untreated ADHD kids show a significant increase in drug abuse. Finally, it causes early school leaving.

Continuous failure does not lend itself to high school completion. We need to find and investigate those students who drop out, not just say, ``Good riddance to these bad actors and actresses.'' We need to have funding and a system in place to test them to find out why they are leaving. These youths may have disorders that, if treated, can lead them to success, even in school.

Anxiety disorders include separation anxiety, performance anxiety and social anxiety, and also have a huge impact on people transforming into adults.

Society is so phobic about mental illness that we excuse this as especially shy behaviour. In some cases it is, but in five per cent it is called ``anxiety disorder.'' These children manage to hide their way into adolescence, with parents talking for them all the way. Then I see them with Sunday night headaches, Monday morning stomach aches, fainting and dizzy spells, chest pains and shortness of breath. They cannot go to school, certainly could not do well on exams, will not go out with peers and cannot begin to think about separating from their parents. Remember, these are all the things teens must do to step forward into adulthood. Instead, they are crawling backward to avoid exposure.

They know they should be doing more, they want to do more and they get angry. They are irritable and are often labelled not as ``sick'' but ``difficult kids.'' They just do not want to go to school. They will do anything to avoid going out into a world that is so terrifying to them. They even subject themselves to physical pain as their bodies bear the brunt of anxiety. This leads to an enormous cost to our health care system as millions of dollars are spent in looking for the cause of their symptoms.

I rarely see a teen suffering from anxiety who does not arrive on my doorstep, usually Monday morning, with boxes full of blood tests, CAT scans and X-ray exams. Anxiety does not go away if left untreated. These same individuals become anxious, even agoraphobic, adults. How can these scared teens who did not accomplish any of their tasks possibly be productive and fulfil their potential?

Again, these teens are just not diagnosed. It is easy to call them ``slackers'' or ``manipulative.'' Many turn to self- medication to relax. We see here the co-morbidity of use of alcohol and marijuana that comes into play.

We have treatments and they work, but we have to make the diagnosis first. When our schools see a teen with a large number of absences, maybe they need to think about having a professional other than a probation officer go to see what is happening.

Finally, I wish to talk about adolescent depression. We have good evidence that about 5 to 10 per cent of Canadian adolescents suffer from major clinical depression.

Many of us have had experience with the pain and isolation of a depression following a personal loss. Imagine if this pain lasts for many months. Imagine the isolation, the lack of ability to concentrate, the lack of ability to socialize or to hope, and imagine that for a youth this takes place at a critical physiologic time when those things are more than essential; they are life promoting.

How do we miss this disorder? Again, we say it is a mood, they are bored, they are loners. Kids just do not get mental illness, you see. The result of untreated depression is as tragic as untreated ADHD. It is a life stopped, unfulfilled. Attempts at self-medication occur here too. We see pot, alcohol and, in depression, sometimes even cocaine.

There is one more thing about depression that you need to know. Depression is the leading precipitating factor associated with suicide. Some say that suicide is the second most common cause of adolescent mortality in Canada, after motor vehicle accidents. It is a statistic that puts Canada among the First World countries with the highest teen suicide rates, even higher than the U.S. I say that some say it is the second most common cause because, after years of working with adolescents, I know that some depressed teens get drunk, get into a car and kill themselves, and that is recorded as an MVA, not as a suicide.

I would like to tell you, finally, that nowhere is the two-tier system of health care as alive and well as in the area of pediatric mental health. I will explain. First, there are definitely not enough pediatricians, and even fewer pediatric psychiatrists, to make these diagnoses early. Many areas in Canada are without these professionals altogether, so where you live counts.

Having said that, there are professionals who can help make the diagnosis and treat these illnesses, but only if you have money, and lots of it. The waiting list to get the public school system or a community mental health centre to diagnose ADHD in Toronto today is 18 months — that is two full school years. That is if you do not have money. If you happen to have $2,000, I can get you a psychologist within a week or two who will make a diagnosis and, if necessary, lay out for the school an extensive program to help your child succeed. Most employer-run insurance programs cover an average of only $300 for psychology. Most public programs cover zero.

In addition, having money counts in getting treatment for the other mental disorders I talked about. Presently, there are effective drugs for anxiety and depression. It is an important aside that in pediatric mental health, these drugs have never been tested in children and youth. We need federal incentives for pharmaceutical companies to run drug testing for children and youth.

Let us go back to the two-tier system. Anxiety and depression are lifelong conditions. As a pediatrician, to start someone on a drug that they may need to use for 50 or 60 years is really frightening. However, there is an alternative, but often, again, only if you have money. There are specific counselling therapies — Dr. Waddell mentioned cognitive behavioural therapy — that treat anxiety and depression as successfully as drugs, but currently, the majority of professionals who offer this therapy are uninsured by most provincial health plans. There are trained, regulated professionals that, if society's will was there, could treat many of our children and youth. I do not hesitate to say that if we had more treatment options, physicians would make these diagnoses earlier, preventing, in some cases, the adolescent consequences of isolation, delinquent behaviour, substance abuse and, most seriously, failure to progress to meet adult potential.

In closing, there are a few things we really need to do. Some are my tasks, and I hope some you will take on, as you already have, as your tasks. Medicine needs to continue teaching its students that children and youth get mental illnesses, and to recognize them. We need to create a seamless system of care for these children, youth and their families so they do not have to renew and change services as the children age. Currently, the treatment approaches are so fragmented that they may actually end in the middle of the school year. We need to encourage more physicians to enter the area of pediatric mental health. In truth, remuneration in this area does not begin to cover the hours spent on the phone communicating with others involved with this child or youth. Special funding should be available for diagnosing and treating these conditions.

Medicine needs to share its knowledge with the judicial profession so they can reach out and help these kids, many of whom come before the courts. We need to rethink the issue of adolescent substance abuse, not as a problem, but that it may be a teen's own solution to a mental health problem, and we have not picked it up. Here again, do not forget to look at our youth who are in detention facilities. Treatment, not punishment, may be appropriate in some circumstances.

As leaders in our society, we need to teach Canadians that mental illness is just that, a disease, probably with genetic, environmental and chemical origins, and that children and teens suffer from these disorders. We need a full- scale public health education campaign. We have to unchain society's thinking about mental illness in children. We need to fund special educational programs that address ADHD and learning disabilities and that are available to all socio-economic groups. Society needs to organize and fund programs to screen teens who are failing or leaving school early and pick up those with treatable mental illness.

We need federal incentives for pharmaceutical companies to run drug trials on children and youth to increase the safety and efficacy in these treatments. We need to expand health care in Canada to meet the WHO definition of health and extend special coverage to trained, regulated professionals who treat these disorders to make treatment available to all socio-economic groups in all parts of Canada. We need to recognize pediatric mental health problems as a national priority and fund research in this area.

If we do not do these things, we leave these families to fend for themselves, and these families and kids often choose isolation, withdrawal, self-medication and even death, over living with the pain of mental illness. They are often lost to society, making Canada the big loser.

Every witness who has appeared before us has talked about the extreme fragmentation of treatment. There are essentially a series of silos and the patient gets kicked from one to the other or may get stuck in one silo. I recognize that you can never just import someone else's model, but is there anywhere in the world that does this significantly better than we do, or is children's mental health a universal problem?

Dr. Waddell: As best as we can tell, it looks like we are not doing a particularly bad job compared to other countries. We have not found anywhere an obvious model that does a good job on this fragmentation issue. It appears that issues with children's mental health, partly due to the reasons to which many of the other speakers have alluded, are complex. They involve multi-causal kinds of situations and many different kinds of people do and should get involved. Early childhood educators, teachers and physicians are just a small part of the equation.

We are not necessarily doing a bad job compared to others. Everyone is sharing many of these problems.

Dr. Davidson: I think Dr. Waddell is better positioned to make this comment because she lives there, but British Columbia attempted to pull it all together into one ministry. However, my understanding was that the people associated with health, particularly the physicians, did not engage with that one ministry. An initiative was attempted, but I am not sure that it has worked that well and I would be interested in hearing Dr. Waddell on that.

Dr. Waddell: In the mid 1990s, British Columbia made a policy decision based on reacting to an acute child protection situation, specifically, the death of a child who was in the care of the ministry responsible for child protection at that time. The ministry took note of the severe fragmentation issue and attempted to pull all children's services into one ministry. There were some difficulties in doing that, however. For instance, hospital services, and specifically physicians' clinical billing services, were not ever fully able to join that one ministry.

Obviously, the school system was a huge player and needed to retain its own separate ministry.

Children's mental health services per se were carried on in the new ministry. It is now the Ministry for Children and Family Development. Those services have continued to struggle. This issue today commands a much larger mandate in the ministry, which also includes child protection. Child protection budgets by far take the greatest chunk of the total resources available.

People in our province have talked about a solution — sending children's mental health issues back to the health ministry, where public health services are also housed. However, when children's mental health was located in that ministry, there were serious difficulties with its being overshadowed by adult mental health — again, a much larger program — and by acute care services, hospital programs and other larger, more dominant programs.

In British Columbia we have a new children's mental health plan, because we recognize that solution has not been terribly effective. Now we will attempt to create a children's network, starting with a joint committee involving the most significant people from the children's ministry and from the health ministry. We recognize that things like doctor and hospital services will likely never move out of the Department of Health and education will have its own ministry, but we wanted a high-level coordinating body that reports to each of the ministers in the key ministries.

We are just embarking on this experiment and are in the process of setting up the high-level network. We are aware of experiments in other provinces. Manitoba and Ontario have tried different configurations. We still need a more unified approach across the country. We hope that mandating a group to report directly to the ministers involved will make people realize that, although it is never possible to bring everything under one roof, we can do much better.

Senator Morin: Thank you to all four witnesses. Their message is outstanding and impressive.

Dr. Waddell made a strong statement. I hope it will be part of our report eventually: Mental health problems constitute the most important group of health problems that Canadian children currently face.

I would have stated infectious disease or some other condition, so that is a really impressive statement.

All four witnesses have come up with a number of recommendations. What can be done at the federal or national level? I realize that much of what you are doing is provincially based. For example, Dr. Waddell did mention research, the establishment of evidence-based guidelines, mental health indicators, information systems and so forth. What can be done at the federal or national level? When I say ``national,'' I mean an interprovincial, federal type of body.

Dr. Waddell: That is an important topic to open up. There are a couple of federal or national initiatives that could be helpful in the short term to set the stage. Co-monitoring is an important motivator. That is a dry term, but we are really talking about things like having a national information system that lets everyone know how they are doing in comparison to other provinces or other regions. It can allow them to see how they are doing compared to a basic set of agreed-upon child-health indicators.

We already have national agencies such as the Canadian Institute for Health Information that have been mandated and set up specifically to look at information and outcome-monitoring data on the health of all Canadians. Children's mental health could be included among the things that those agencies examine.

The federal or national level could also help by setting up some kind of national presence to bring together provincial and regional leaders. There used to be federal-provincial-territorial working committees on children's mental health. Those committees still exist for adult mental health problems. Reconstituting a children's mental health committee could raise the profile and draw in some of the helpful stakeholder groups, like parents' groups.

The federal government can also help with the research agenda and with systematic knowledge dissemination. Evidence-based practice, for instance, is attempted in many areas on a discipline-by-discipline basis. Psychologists have their own practice parameters; psychiatrists have theirs. At the federal or national level, systematic dissemination of knowledge about evidence-based practices across disciplines would be helpful. Knowledge development and dissemination and then monitoring of the overall system are helpful starting points.

Dr. Sacks: We are still operating in crisis mode in child and pediatric mental health. We really do operate at that level on a child-by-child, team-by-team basis. Perhaps I should not refer to a program that is not fully implemented yet, but I wonder if we do not need something similar to a national immunization program in this area to catch these kids early before they get sick.

In fact, if any of our programs are successful, it is some of our prevention programs. They can catch these children before they get clinically sick and stop functioning.

I wonder why we cannot fund research to find a tool like the little immunization cards that kids must have when they start school. We could have a set of questions to ask the family when those cards are issued. That will not pick up everyone, but it could pick up the high-risk kids. We know that one of the highest indicators of depression in teens and children is having a parent with a mood disorder, so let's ask.

First, we need a public information campaign so that no one is embarrassed to say ``yes.'' We can also ask if there has been a loss or a death in the family. Is there anyone in the family who dropped out of school early? Somehow we need to pick up which kids are high-risk. We will not necessarily take them out of the class and treat them; however, where it is indicated, we can institute programs like cognitive behavioural therapy, which really does work without drugs for many of these kids early on. Give them social skills so that they are not isolated, so that they do not become victims. We know that some bullied kids respond in certain ways because they do not have social skills or because they already have an anxiety disorder.

That is a key place to identify young children with problems, but we must start by educating the public that it is okay, that this is a disease.

Dr. Davidson: I agree with what has already been said. I should mention that dirty ``s'' word, stigma. Stigma is one thing that kills our efforts as we try to move forward. Raising the profile of mental health and mental illness, as this committee is doing, is extremely important. We must address the stigma of mental illness so that sufferers feel comfortable in seeking out help at an early stage.

Dr. Waddell mentioned the program in Australia that addresses anxiety disorders from a universal perspective by including training in the school curriculum. That is a very good example of something that we could do better. In other words, we need universal programming.

When we go to school, there are many compulsory credit courses. One thing that most of us do as adults without taking any compulsory course is parenting. If we could enhance our skill sets as parents, perhaps that would be helpful.

Senator Cordy: Your advice, Dr. Sacks, about providing schools with information is extremely important. I was an elementary school teacher and taught primary grades for a number of years. The public has to be made aware. We need an education program.

I also found that sometimes, a couple of weeks after the school year started, particularly in grade primary, you would phone the parents and say that you noticed such and such a behaviour in their child and ask for details. Their response would be that the doctors' advice was not to tell the school because they did not want the child to be prejudged.

It is important that medical personnel are also educated in this regard. The information that you have, while you do not want to stand on the street corner broadcasting it, is important to the bodies dealing with the child so they are aware of what can best help.

Dr. Sacks: Absolutely. My first recommendation is to train our medical personnel better. One of the things we need to train them in is in giving ``bad news.'' As a pediatrician, I find it easy to give bad news because I know I will follow it up with, ``This is what we are going to do about it.'' I cannot think of anything in pediatrics where I cannot say, ``and this is what we are going to do about it,'' even when telling the worst kind of news.

We have to be careful. If we get these kids, we then have to ask what we are going to do with them. I think we will get a lot of kids who still have potential. If we give them some skills, they may make it through those critical periods that we are talking about.

You reminded me of something I say when I talk about school programs that I wish existed, and that is, I do not want teachers to become treatment people. What they need to do is teach. When they see children not learning and they say, ``Well, I will teach them this way and not this way,'' and they still do not learn, then we have to find out what else is going on. Maybe it is something at home. Maybe it is something in the child's head.

Certainly that is one of the coordination factors we need to undertake: Education at the medical school level and in the public education system.

Senator Kinsella: It seems to me that one of the most horrific examples of failure in the child mental health delivery model occurs when we have a child suicide. To build on the doctor's observation about stigmatization, is there not much to be inferred from keeping quiet about the real numbers of teenage or child suicides? For example, what are the real numbers in Canada?

Dr. Davidson: About 12 to 13 per 100,000, for males and females. This is 15- to 19-year-olds. It would be lower if we included 0 to 14.

Senator Kinsella: Is that about 50 suicides per day?

Dr. Davidson: No.

Senator Kinsella: How many per day?

Dr. Davidson: I do not know what that translates into.

Senator Kinsella: Do you agree that we need to shine light on suicide, which is a failure on society's part, and in so doing, put the light on the state of the mental health delivery system in Canada, because here is a real example of where it is broken?

Dr. Sacks: That is the total life lost. With some of the other conditions also, a life is lost.

You are right, we cannot do it on an individual case basis because copycat suicides do exist and we must be careful about that. There is no reason, however, why we should not, as child advocates, make it known that children can become so desperate that this is the only recourse open to them.

The newspapers do not want to hear about it, the media do not want to hear about it. This is not as action-filled as a full-fledged war or something. As I said, we must be careful about using the cases of individuals, but I absolutely agree with you that people do not recognize that this problem truly exists in Canada.

Senator Kinsella: On a different topic, I recall a few years ago how the works of Wolfensberger and the mantra of normalization became the model for a broad and community-based service delivery. My observation — and correct me if I am way off — is that that is a great model provided you have the resources, particularly the professional resources.

Would you comment on that first?

My anecdotal observation is that many of the people we pass on the streets, whether in the wintertime or other times, some of them quite youthful, would probably have been in an institution in other times. Where is the middle ground?

Dr. Davidson: Absolutely, community-based services are a very important way to go. They work particularly for many of the universal, targeted and clinical programs that are more on the mild-to-moderate side of the spectrum. You need to back them up with a safety net, I think, of specialized services that do not work in a fragmented way, but in a continuum with the community-based services. Then, when things are a little better, the individual can go back to the community for service and the specialized service can then deal with other such people.

Dr. Steiger: I wanted to follow up on that comment as well in stressing that the community-based services are certainly essential and a key factor in proper health care delivery. It makes service accessible and non-threatening. These services really do need to be backed up with well-established, ultra-specialized programs. A kind of buzz phrase often used is that it is not good enough to practise what the latest textbook says; we have to be writing the next one. That kind of constant evolution of new practice standards, which comes from and is inspired by ongoing research and a kind of race between research findings and clinical developments that is essential to a creative, vital practice, mainly goes on in specialized clinics.

We need to think of a way to develop some coordination between the more academically based, specialized programs and real frontline care.

Dr. Davidson: I wanted to make two points about the gatekeepers. The first point is that if the school system is one of the important gatekeepers, in a time of need, when budgets are getting cut, the first thing that the ministries of education or the school boards are cutting is special services. Therefore, we are losing our frontline social workers and psychologists. That is going to ramify through the system.

The other thing that really troubles me is that in Canada, residents are trained in family practice and are going out into the community and practising.

Now, honourable senators have seen the prevalence rates. About one out of five children and youth will have a psychiatric illness. These family doctors will see children and youth with psychiatric illness, but they are not being trained to deal with children and youth with mental health problems. Their mandatory training is in adult mental health. What they end up doing, if they identify the problems, is generalizing their management approaches based on those you would use with adults.

Getting back to Senator Morin's question about what can be done — I think childhood psychiatry needs to take some responsibility for this — we need to work closely with family practice to ensure that we are an active, aggressive part of the curriculum as they train family doctors.

Dr. Sacks: Getting back to Senator Kinsella's suicide question, 70 per cent of teenagers who committed suicide saw a physician within a month previously. There would be a few things that might happen, even if it was picked up. One is they may not have been trained properly. Two is I can tell you that every Friday, I get calls from rural communities in Ontario about suicidal kids. They cannot get funding for what they call ``an observation nurse.'' This is a nurse who watches to see that they do not hurt themselves. Do I have a place for them? I do not, by the way. In fact, we have closed hospital beds for teen mental health in Toronto.

More importantly, it goes back to the fact they had no resource in their hospitals in these rural areas, as we mentioned before. We need to increase funding for non-medical people to come in to see these kids — psychologists and social workers. This has to be part of the system of mental health. It can be and should be special, different maybe from the medical system that we are working for, so that it can get funding. This is a crisis.

Senator Kinsella: Indeed, it was precisely this point that my third question was focusing on, with particular reference to clinical psychologists and those who specialize in child psychology and child clinical psychology. The witnesses have made reference to the fact that if not in all, certainly in most jurisdictions across Canada, medicare does not cover the fees for a psychologist. Hopefully, Chair, we might hear from the various colleges of psychologists across Canada. That might be one area where we could make a positive recommendation.

The Chairman: We will do that.

Senator LeBreton: That is a perfect lead-in to my first question. Dr. Davidson, you talked about pediatric psychiatrists. It takes them longer to learn their practice, and yet they earn less. I want to know why that is. Is it because they are not funded through the public health system?

Dr. Davidson: It is funded. I will be my forthright self. Universal health care is universal only for the services that are insured. For services that are not insured, it is not universal health care. By the way, I am a child psychiatrist, so I feel better speaking about child psychiatrists, but I am a firm believer in the interdisciplinary approach. I do not mean in any way at all to exclude psychologists, social workers, occupational therapists, nurses and child and youth workers, whose roles are absolutely vital.

If you want to practice child psychiatry properly, you will go into schools; you will work with teachers, the police, child protection agencies, with extended families and more. I can only speak in regard to Ontario and its health insurance plan. You are remunerated for the one-on-one work with the child or the child and the parents. That is one of the issues. We have to do a lot of work that is not insured.

Senator LeBreton: That would be an impediment to even getting into this field.

Dr. Davidson: Absolutely.

Senator LeBreton: The other point in your presentation was that the current system fosters mental health stigma — the ``s'' word. Could you give an example of why you said that?

Dr. Davidson: I will give one example from my own hospital. When patients come into the emergency room at the Children's Hospital of Eastern Ontario — and we have done things to try to improve, so I am giving you something of an old example — they go to the triage nurse. Inevitably, no matter how severe their problem is, first of all, they feel uncomfortable talking about their mental health problems in a fairly public forum. Second, they will end up sitting in the waiting room far longer than most people with moderate physical health problems.

Often, patients and families end up asking for a segregated waiting room so that they can feel more comfortable. That suggests to me that many of the people who need help do not come to get help because of the stigma of mental illness.

Senator LeBreton: Or when they arrive, there they sit and then they just leave.

The Chairman: Dr. Waddell, given your experience on the ground and with your clinical unit in B.C., do you want to comment on Senator LeBreton's question?

Dr. Waddell: One of the things we have been talking about is the constant feeling that people delivering any kind of services are overwhelmed, cannot keep up with ridiculous waiting lists and never feel that they will be on top of the situation. That does lead us back to the necessity of taking a different look at some models of delivering care in the first place, things that keep us tied to traditional, one-to-one clinical treatment models, whether that is medical, psychological or any of the other kinds of practitioners involved. They are simply never going to do it.

We do have some examples of innovative kinds of models that allow us to extend our reach. I am thinking of things like some of the alternative payment models that can be helpful in liberating physicians from the fee-for-service billing systems, but also things like shared-care models being piloted with adult mental health and that merit close attention for children's mental health. For example, providing multidisciplinary team support to primary care practitioners, not necessarily just physicians — it could also be public health nursing teams — in their own context where the children are arriving naturally. That takes health practitioners out of the traditional one-to-one setting and extends their reach much more broadly by allowing them to really work with all of the patients, with children in a group.

I also wanted to add one more response to Senator Morin's question about what might be some things that a federal group such as yourselves may want to focus on that know one else is. One issue pertains to what are our models of care and what different ones could we be looking at and trying out much more aggressively?

Another thing dealing with this clinical black hole and the feeling of constantly being overwhelmed comes back to this issue of health promotion and prevention. Given the way health policy mandates are divided between federal and provincial governments, health service delivery has been largely left, and appropriately so, to provincial governments. What happens in times of budget stress is that prevention and health promotion, frankly, are ignored even more than usual. The federal government could play a strong leadership role here that many of the provincial governments are not able to play because they are constantly trying to keep up with the basic clinical treatment demands that they face.

The federal government has the luxury of not being so close to that frontline and could take the opportunity to do something like lead a national initiative, something on the scale of, for example, what has been done with the early childhood development programming, using federal funds, federal leadership, and specifically addressing an area like children's mental health and prevention of disorders that has not been addressed, and will likely not be addressed, provincially.

Senator LeBreton: Dr. Steiger, on the issue of eating disorders, obviously the focus is more on adolescents.

You talked about early intervention. Is there a trigger point or a time in a younger child's life when people in your profession, or indeed even families, can detect the early signs of an eating disorder? Has that been studied at all?

Dr. Steiger: It is a very intriguing question, and unfortunately, we are actually accumulating findings showing increasingly earlier onset of eating concerns. There are studies that document clear weight preoccupations, dissatisfaction with body image and kids as young as four or five feeling they must be on a diet.

These kinds of preoccupations are a manifestation of something so deeply woven into the fabric of our society and our own body preoccupations that we have not yet been able to study at what point the most effective intervention can be achieved. That is one of the roles for research funding that I was speaking about earlier. We need to know whether we can intervene at an early enough stage to head off the development of this problem.

Dr. Sacks: The Canadian Paediatric Society, which runs nationwide surveillance programs of rare but not so rare conditions, has just added early-diagnosed eating disorders to their list, so we should have numbers soon. They are not so rare, unfortunately.

Dr. Davidson: An interesting finding, if you look at the literature on restrictive anorexia nervosa, is that there has never been a case study of someone who developed it but who was born blind. I am not sure how early this whole thing starts, but it seems to me that if you can see yourself, you may be at risk of getting it.

Senator LeBreton: Finally, you talked, Dr. Steiger, about one-third responding well to treatment. What happens to the other two-thirds? Where do they go?

Dr. Steiger: The reality of these disorders, which are probably best characterized as being frequently relapsing, prone to chronicity, unfortunately, in an unacceptably large number of people, is just a progression from childhood eating disorders into chronic, well-entrenched eating disorders in adulthood. That is one of the reasons why you have a higher prevalence of eating disorders in the adult age group. Unfortunately, there is an accumulation of eating disorders that carries over.

That is not the sole explanation. In many cases, you have later onset. The onset of bulimia tends to occur more in the transition into adulthood, but this too is a real call for more research into treatment efforts and also early intervention. Presumably, the earlier the intervention, the more effective it will be. As with most disorders, and it will be true for all mental health problems, one of the strongest indices of poorer prognosis is duration over which one suffers the illness. Even though we may not have the data yet, there is a basis on which to presume that if you catch it early, you will do better.

Senator Fairbairn: Thank you very much to all of you. This is obviously a huge issue. Dr. Waddell touched on something that has been troubling me throughout the discussion.

I preface my remarks by saying that I have been involved in the issue of literacy for 19 years. I discovered it on a Senate committee many years ago, and then I was pulled into it by a friend with a daughter who had learning disabilities. The first speech that I ever gave outside this place was to a mental health annual meeting in the province of Alberta.

From the beginning, I have been plugged in across areas of jurisdiction. We are a federal committee. Dr. Waddell and others have made a point in their discussions about the difficulty of providing treatment, resources and promotion at all of the levels to which this issue takes us. When it comes to our responsibilities, we have had success in early childhood development. That is something that we can engage in on our own; however, through negotiation, happily, with Jane Stewart and her counterparts in the provinces, there has been a broader agreement that we will work together on that. We do that on issues like adult literacy and learning disabilities. As a federal government, we have the ability to work in the adult area, but we have been able to work around jurisdictional barriers and work together with the provinces.

It seems to me that somehow, we must find a room in which the two levels of government can sit down together on the question of mental health and young people. We will have difficulty unless we can find that room, particularly during the school years. We will have to think creatively about promotion of health care, mental health and everything else. We can do that kind of thing up to a point, before we step across the line.

We should be looking at what we can do within our own jurisdiction, but at the same time, it does obviously cross every border and boundary. From your experience, perhaps you can give us advice on where we can find the guidelines, and that room, so the federal and the provincial levels can come together to help young people, instead of one doing something for the very youngest, but not being able to have the same kind of influence at perhaps the most dangerous ages of all. I do not know whether I am making myself clear, because jurisdictional and constitutional discussions in Canada are never clear, but there is a problem.

The Chairman: I can see that Dr. Davidson wants to comment. I will add one point to what Senator Fairbairn said. This committee has never been hung up on jurisdictional niceties. The example I give you is the care guarantee that we proposed in our report, which the federal government had no way of implementing. It is interesting to note that it was in the Speech from the Throne in Ontario yesterday. It was in the Government of Quebec's program that Premier Charest announced. It is now coming in Alberta. There may well be a role for us in getting an idea rolling, even though we cannot, in any legal jurisdictional sense, enforce it.

Dr. Davidson: I do not know a lot about politics, but when you talk about getting the right people into the room, I do not know who the right people are at the provincial level because there are so many fragments. This gives me a chance to say what I think you already perceive about the child and youth mental health arena. The way you profile child and youth mental health in your report is critical, because it could just get buried amongst all the adult material, as usually happens.

Senator Fairbairn: Exactly.

Dr. Davidson: I have never seen an inter-ministerial anything at the provincial level be effective. I do not know whether one could raise the profile of child and youth mental health to a point where it could be addressed at the level of the premiers, so that they have to assume responsibility in some way for pulling this fragmented system together. Maybe they are the right people to get into the room.

Senator Fairbairn: As Senator Kirby has said, even in the report we have already made, while we could not do something directly, things we suggested are starting to occur at that very level. My point is that this is something on which we really need to work. We can make a real effort to take this child and youth issue and raise its profile.

Maybe we can also construct a few suggestions on what should be done and what must be done at levels other than our own.

Dr. Davidson: Dr. Steiger's point is extremely important as well. How does one make the transition from youth into the adult system? That is another quagmire that needs to be addressed.

Senator Cordy: Thank you. It has been most informative. I will start off with Dr. Steiger and eating disorders. You talked about education and health promotion. Is it working? One looks at the images that are portrayed in the media and the positive reinforcement that young girls, particularly, receive, at least initially. As time goes on and some girls get thinner and thinner, they may not receive positive reinforcement. However, among their peers, initially, a loss of five or ten pounds will attract comments about looking great. That gets more attention than the education coming from the Department of Health or from others. Is education working?

The Chairman: To piggyback on that question, we were told in our previous health study that one of the reasons why smoking is more prevalent among teenage girls than boys is they believe that they will eat less if they smoke. Is that true?

Dr. Steiger: That certainly is one rationale that we hear from our patients for continuing to smoke. It is often listed as a cause of smoking. They are not really interested in the cigarette.

I think anyone who works in the area of eating disorders must feel a little as I do sometimes; that is, as if I am standing on a beach as this tidal wave of social pressure comes rolling in, at least with respect to favouring thinness. That is probably where a much more concerted social effort is required.

I will deal first with your question about the efficacy of prevention. We have some results to show that we can intervene at an early age through schools and institutions like that. We can challenge some of the beliefs of kids who favour thinness by addressing the risk of eating disorders, the idea that thinness is the be-all and end-all, or that self- worth has to be attached to weight. The results also show that which you were alluding to in your question: the beneficial effects are short-lived and are washed out by the tidal wave I spoke of after about six months. Clearly we must invest in the development of more effective efforts.

Some of the more interesting prevention efforts actually bring together health practitioners, teachers, parents and kids into the same kind of program. We can then really challenge the basic beliefs that are transmitted from generation to generation and that promote eating-disorder development. That may be one of the many levels where governments can become involved, because we are talking about real public education and media campaigns to change the values that we associate with thinness.

Spain actually has legislation against the use of overly slim models in certain kinds of advertising. That may sound overly concrete, but it is one way in which governments may become involved. We must mount a campaign with a power that matches that of the tidal wave. It starts by re-evaluating closely held values.

Senator Cordy: It is amazing the number of young girls who are continuously worried about thinness. I have two daughters who have said to me that so-and-so throws up every time she eats. These are pretty average kids who are suffering from eating disorders.

Dr. Sacks, we have talked about many children not being diagnosed. Why is that? Is this a result of society's thinking that young people do not suffer from mental illness?

Dr. Sacks: It starts with that very premise, that young people do not get mental illness. As I said, this is new to the health field — 25 years new. Second, we are not teaching our medical students to pick up early signs and symptoms. I do not expect parents or teachers to do that unless we start educating them. Finally, as I said in relation to suicide, when one diagnoses something, it would be nice to know what to do with it.

At this point, the services are just not there. We have learned to think in terms of prevention, diagnosis and treatment. Certainly we do not have prevention yet; we do not have treatment in place yet. To isolate diagnosis makes life very difficult for us on the frontline. They say, ``Now what will you do, doctor?'' And I answer, ``Well, do you have private insurance? Fast or free?''

Dr. Davidson: We run a universal program called YouthNet that has given us a data set of 12,000 youth. A full one- third of youth — and roughly 40 per cent of that third are male — feel that if they have a mental health problem, they have to tackle it themselves and they should not tell anyone. That is partially because, as an adolescent, you are meant to be invulnerable and you want to be more independent. It is also partially because of the stigma.

Senator Cordy: We want groups to work together, but school boards are facing cutbacks, and unless there is a certain diagnosis, very often the special service resources are not available. Teachers and parents can explain the difficulties the child is having, but unless there is actually a medical diagnosis, the administration may not pay much attention.

Dr. Sacks: I will also say that if you really want to scare a teacher, tell him or her that one of the students is missing school due to depression and that the child may arrive late because he or she cannot get up in the morning. It is very frightening. Again, education is essential.

I run a CBT group for anxiety disorders in the community hospital where I work. After initially dragging them in and someone opening up the conversation, they look up because someone has said something that makes sense to them. There is no better relief for these youngsters than to know they are not alone. These kids are struggling, thinking they are the only ones on earth who at 14 must sleep with their parents or who cannot go to camp — that is a ``biggie'' in Canada. It is really quite amazing.

I think the kids would get help if we de-stigmatized it. We have to start with parents and then schools; get at it that way. We need national programs to teach people about child and adolescent mental health issues.

Senator Cordy: You are absolutely right.

Is there an increase in the number of young people with ADHD or is it just being diagnosed more?

The Chairman: This is a surprising moment of silence from people who are very talkative.

Dr. Sacks: The diagnostic tool is fair; it is not well taught to the frontline workers who make the diagnosis. To make a good diagnosis, one needs specialized services that many cannot afford. That is one point.

Second, the treatment for ADHD is use of stimulants, which are excellent. They also work for people who do not have ADD and ADHD, too, for a while. The actual numbers are not as clear as we would like. Those of us who have been around a while know that this is a major problem in our school systems, for our kids, for the parenting of these children and in our emergency rooms. We have a ``sew and go'' policy. Kids with ADHD bounce off the walls; they are always getting stitches and broken bones. No one ever asks why. They just say: ``You have a number of scars; you are a real tough guy.'' No one really thinks there may be an underlying medical diagnosis there.

Again, the incidence of ADHD is very difficult to determine but it is definitely not small.

Dr. Davidson: The other point is who is diagnosing it. When I came into practice 20-some years ago, if I made a diagnosis of ADHD and tried to talk to the teacher about it, often the teacher was highly resistant to this diagnosis, and even more so to the management of it, which is, of course, a combination of medication, behavioural approaches, parenting strategies and cognitive approaches. Today, we are getting referrals from teachers, saying this kid has ADHD. I do not really know how to answer your question, except to say that it is now a more accepted diagnosis in the educational system.

Senator Fairbairn: What about parents themselves? To what degree is there denial, not wanting to admit that there is anything wrong?

Dr. Davidson: There are several aspects to that. The first one is the denial that you are talking about. The second is the failure of self-identification. Sometimes I think that kids come almost as back-door referrals. In the process, the parents say, ``Oh, that is what I have had a struggle with all my life. I did not identify it in myself, so how can I identify it in my kid?'' That brings me to that other point, about how important working with children and youth who have parents with mental illness will be. As we have all indicated, we are so busy putting our fingers in the holes in the dikes and trying to deal with the overwhelming demands of active cases that I do not think nearly enough attention has been paid to working with these high-risk children.

Senator Robertson: Dr. Sacks, you mentioned something that caught my interest. When discussing the mental health problems of children and youth, you talked about genetics and environmental and chemical effects. I believe that is what I heard you say. Then I also heard you say something about prevention. I know these cross over, or at least we have been advised that they cross over, but have you any idea what percentage of child and youth mental health problems would be a response to genetic, environmental and chemical factors?

Dr. Sacks: In the disorders that I spoke about, ADHD, anxiety and depression, the genetic load is probably quite significant. As we work more through the genome and genetics, we will probably find that is the case throughout. However, we are finding that if we pick up these young children early in the way we described, through knowing the parental history, in fact there are programs that have shown, especially for anxiety, that if you give these young people social skills training early on, if you give them relaxation tools, which sounds very basic, and tools of self-talk, you can avert some of the crises of anxiety disorders. The fact that it is genetic is not an excuse for not trying to find programs that work. We must study these programs before we implement them. Some of us who are older have said that everything will be blamed on genetics and we do not have to worry, but in fact I think that we will learn that we can do much with the genes with which we are born and we will have to learn how.

Senator Robertson: That is helpful.

Mr. Steiger: If I can add to that, although it is a little brash to say this, because we have not pinned it down with research yet, it is very likely that all of these conditions have some sort of genetic substrate. What is fascinating in our findings is the way in which we see experience and environmental pressures turning on the effect of a gene. In my particular area, we are seeing the impact on certain biological processes that are programmed into some people that might have absolutely no expression if it were not for the compulsive dieting that certain people do, putting themselves at risk.

Not only is that very important in terms of understanding what we treat and that having a genetic vulnerability does not imply hopelessness about the utility of treatment, but also in terms of the stigma. Mental health problems have to be understood as not a sign of moral weakness or moral bankruptcy on the part of the sufferer. Sometimes, it is important to realize it is a little more like walking along the sidewalk when the piano fell. Some of the factors that converge to explain why someone develops an eating disorder, or any other mental health problem, are really quite beyond the volition of that person.

Dr. Waddell: If you can take your mind back to the table that we presented earlier, listing an array of children's mental disorders, it is fair to say, and I hope that most of the colleagues at the table would agree with me, that pretty much all the disorders involve some interaction between genes and environment when it comes to what causes the problem. There is also a spectrum, however, in which some disorders have more of a genetic ``flavour,'' if you will, than others. For instance, schizophrenia and bipolar disorder are more likely to be influenced by genetic vulnerabilities than are things at the other end of the spectrum, such as conduct disorder. There it looks like there may indeed be some genetic influences, but the environment and the impact of early parenting are so influential that it looks like serious parenting problems involving child abuse and neglect are the real cause. The environment outweighs the genes in that situation.

You also made a comment about what we can do or what we can hope for from prevention programs. It is fair to say that the research evidence could be better, although many things are emerging. However, there is sufficient evidence that we can intervene in some things that do have a strong environmental component, like anxiety, depression and conduct disorder in particular.

The other message is we have been talking a great deal about clinical programs and school programs, all of which are important, but prevention really works better if we can put it into effect as early as possible, even prenatally. For instance, prevention does not start at zero; it starts before that. I would remind people again about one of the most successful prevention programs that could be a model for tackling many of these things, which is the work based on public health nurse home visitation, a very simple, old-fashioned model. You take parents at risk in the prenatal period. You work carefully on ensuring healthy parenting and healthy personal practices, trying to prevent things like fetal alcohol syndrome and other sorts of issues that can be established even before birth, and then working with parents closely over a couple of years to monitor parenting practices to try to prevent some of the things that may be precursors for later disorders. By investing in this over the first two or three years only, you can prevent a host of problems later on and do a great deal to dampen down these enormous requirements for clinical services that we cannot meet because we leave things until children are 5 years old or 15 years old.

Prevention is not possible across the board, and we need to weigh many of the important things going on in genetic research, but there is sufficient evidence now to warrant acting, particularly for those disorders like anxiety, depression and conduct disorders, where there is a substantial environmental component.

Senator Cook: Thank you for some compelling and complex information-sharing. You mentioned genetics. I am wondering what responsibility the state has for parenting issues and where we go with that. That takes me to the environment to which the child is brought home.

It is accepted in our society that both parents work. Sometimes there is only one parent and that parent works. A sitter, nanny or daycare manages that child. I wonder if many childhood diseases are increasing as a result of changing lifestyles.

We talk about early diagnosis leading to appropriate treatment. Parents only see their young children when they are being bundled into a snowsuit to go to the daycare. They are picked up at 6:00 p.m. and are out somewhere while supper is put on the table. We are in a cauldron with this parenting business. Would any of you like to comment on the environment in which we see the child?

There is also the parent who would like little boys and girls to go to ballet, guides, scouts or martial arts. Those children are over-programmed, too. What can we as a committee do to ensure that there is some stability, if nothing else, in that child's life?

Dr. Sacks: Those who have a predisposition, genetically or chemically, will be in a weakened state. That is why we are seeing as many kids as we are. This is a difficult time for people who need a slow-paced, consistent, close-knit family. Such a lifestyle causes vulnerable children to present themselves earlier.

You are saying that we going at such a pace that maybe we do not recognize when our children are in pain. Again, we need to teach the public about signs and symptoms. The little kid with the stomach ache or headache means something else may be happening that should be investigated.

Society has caused these conditions to be much more apparent earlier. That may be an interesting insight into why we see so many of these young people.

However, it has not made it easier for people to come forward. It has not made it socially acceptable to come forward with the conditions that we have been talking about this morning. The parents are stressed out and trying to do the best for their kids, but perhaps we need to make it easier for them.

Dr. Davidson: That is a really insightful question. We know that the definition of the traditional family in Canada changed several years ago. To simplify it, the have kids are over-programmed and the have-not kids are in a fairly fragmented environment. We do know that most parents are doing the best they can.

The way in which we tackle this is critical. The last thing we want is to have parents feel that they are not adequate, or they are not doing a good enough job. Maybe we have to focus much more on lifestyle, and perhaps change of lifestyle, without pointing any fingers.

Dr. Waddell: We have talked a great deal about mental illness, mental disorders and things that require treatment. There is also a great deal of work, and certainly huge bodies of community and personal experience, regarding what creates mental health for children.

I want to highlight some wonderful, long-term work in Hawaii by Emmy Werner on children and populations at risk, such as the have-not kinds of kids to whom Dr. Davidson was referring.

What is it that enables children, even from some disadvantaged circumstances, to nevertheless go on to do well and be what we might call ``resilient'' or to thrive? Her work seems to depict some essential elements of positive mental health ``goods,'' if you will, that the children need in order to be resilient and overcome disadvantage. The kids who did well had good learning abilities, enjoyed basic good health status and were connected through their parents, their communities or other sources to some sense of higher meaning, values or importance in their role in the world. The other crucial aspect was that kids needed the presence of one caring adult, one person in their life long term who was crazy about them and stuck with them. It did not have to be a biological parent, but every kid did need to have one adult who was there for him or her.

That is perhaps a very minimal standard if you are talking about the most basic things that children need for mental health, but I do not know that we could say that all Canadian children currently enjoy that. However, it certainly may help to focus things regarding what we posit as mental health goals.

Mr. Steiger: One measure of health might be adaptability to one's environment. We have to understand better the intrinsic factors that might knock one person out of balance more easily than another. I do not want to underplay in any way the importance of the social environment and the kinds of social and familial supports to which Dr. Waddell was referring.

These are evidently essential. We know that unacceptable experiences, such as childhood abuse, invariably figure among the risk factors for some of the more important mental health problems that we face.

In that same regard, there are certain areas, the eating disorders area in particular, where it may be possible to identify particular social factors and pressures. There is excellent research by Anne Becker, who looked at the impact of the introduction of television on an island community. She found a dramatic increase in preoccupation with weight and dieting among kids in that population. There is a fairly direct and simple relationship that could be targeted as a means of health prevention and promotion.

We can broaden that from simply saying that eating disorders or mental health problems are related to something as simple as dietary concerns. We are a kind of ``more-ish'' society. We do not have good concepts of limits or ``good enoughness.'' As a result, that presents a tremendous challenge to anyone who does not have an internal sense of where ``good enough'' lies. Perhaps that is another thing that we should encourage through schools and through the way we raise children. We should give that to our children.

Senator Cook: I am sure that in 10 years we will be dealing with addiction problems among young people using computers. I am convinced of it.

Can the state intrude into family life, and how can we help? As the chairman knows, I always go back to population health. I prefer to focus on wellness and population health. There is an opportunity for this committee, with your help and expertise, to make a difference there. It will be in the wellness area, and it will be in population health, given the way health is delivered through the federal to the provincial regimes. Thank you.

Senator Léger: There is power in the media image and fashion shows. Parents are dressing a six-month-old baby in Christian Dior. When the children are two or three, they are all dolls. It is costing immense amounts.

Should some of that teaching be done and should we hear more about that power? The child is born and he must be very cute. It is not surprising that when one becomes a teenager and spring is here, all the belly buttons will also be on display. Those who cannot do it feel inferior. That is the power of the image. That is all I wanted to say.

The Chairman: I thank all of our witnesses today. If you have any further thoughts on this issue as we progress, please feel free to contact us with your views. We are at the early stage of our study and your comments this morning have been helpful.

The committee adjourned.