“Growing up in Canada is like a race. I don’t mind if my child is in a race, as long as the race is fair.” This message, oft-quoted by the late Dan Offord, a renowned Canadian child psychiatrist, is one that grown-ups across the political spectrum can support. If we think back to our childhoods, we remember the kids in our school for whom the race was far from fair: the social outcast who struggled to understand in class; the girl who cried all the time and who missed so much school; the explosive kid, avoided by his classmates.
We continue to fail our most vulnerable children. Canadian research studies estimate that about 14 percent of children between the ages of 4 and 17 struggle with clinical levels of emotional and behavioural problems. Yet only a quarter of Canadian children with clinical levels of difficulty have access to mental health care. Surveillance research suggests that neurodevelopmental disabilities such as autism spectrum disorder (ASD) are increasing in prevalence. And we have evidence that childhood mental illnesses and neurodevelopmental disabilities carry a high, chronic burden of suffering and high costs for society.
As a child psychiatrist, I try to help get kids at risk on track and back in the race. But with all the silos in our current mental health care system, I often feel like I’ve introduced them instead to a pinball machine of referrals, wait-lists and missed opportunities. In Ontario, for example, children wait 12 to 18 months to be assessed for potential ASD and then often wait another one to four years for “early” intervention. Such waits are excruciatingly stressful for parents. Furthermore, they undermine the potential benefits of treatment, thus decreasing the efficiency of the health care system.
To make the race fair, we need a strategic shift in the landscape of pediatric mental health care provision. Instead of challenging families to navigate a complex mental health care system governed by multiple ministries and agencies, policy-makers should map the delivery of mental health care services onto children themselves by tailoring services to support their complex developmental trajectories and contexts. In order to achieve this, health services delivery needs to be informed by the science of child development.
The theory of developmental cascades—how early advantages or disadvantages upstream in a child’s development influence multiple pathways of later skills, health and well-being—is a recent framework that offers a particularly compelling road map for more effective child health care. Longitudinal research in childhood mental illness and ASD indicates that intervention programs are more likely to be effective if delivered during sensitive periods of child development, when rapid growth in specific foundational human skills occurs.
For example, early intervention programs for children at risk of ASD target crucial toddler milestones such as shared social engagement and language development. These early pivotal skills may have spillover effects that influence multiple aspects of child health and development (such as emotion regulation and academic success). Although they are developed for children with ASD, such early intervention approaches may offer benefit for a much wider range of children at risk of adverse outcomes (for instance, language disability, attentional issues and attachment difficulties).
In contrast, recent evidence from a large Canadian follow-up study of over 400 children with ASD (the Pathways in ASD Study) suggests that certain important developmental skills appear to be more strongly linked to future development near the time of diagnosis and then become more independent and entrenched over time. Thus, relying on specialist assessment and clinical diagnosis as a gatekeeper to evidence-based services may miss out on earlier windows, when intervention would have yielded stronger or more pluripotent effects.
A developmental cascades model therefore provides a theoretical scaffold for outlining a system of universal, targeted and clinical mental and developmental health care. Community-delivered, evidence-based mental health promotion, prevention and intervention programs that target “upstream pivotal skills” may offer wider health benefits while easing burdens on clinical services and alleviating stress for families on wait-lists. Children with more persistent or heavier burdens of impairment may then require more intensive treatment that is tailored to their mental health or developmental profile.
Such an approach will require more intensive and sustained investment in child development research, its translation into models of intervention and, importantly, rigorous evaluation of such interventions (e.g., randomized controlled trials of effectiveness). Economic studies indicate that evidence-based, developmentally sensitive interventions offer significant returns on taxpayer investments. Most importantly, such investments are crucial to easing the burden of suffering of Canadian children at greatest risk of falling further behind in the race.