UPDATE: A shortened version of this article has been featured in Teacher Magazine.
“Guarantee Access to Mental health care for Every Child” is written for all British Columbians, but especially for the parents, caregivers, families, and educators who raise children. The purpose of this article is to make the case for guaranteed access to qualified mental health care for every child. I also propose actions toward this goal: (1) to support children’s growth and learning, (2) to prevent future mental health crises, and (3) to invest in a stable economy and society in Canada.
There are five sections which cover what you need to know about the issue and how we can achieve the goal of guaranteed access together. Reading all five sections will take 30-40 minutes, and I recommend you read them in order. If you are interested in speaking out on this issue, there is also a sample letter to an MLA in the last section.
Contents
Contents
There are many kinds of mental health care services
Mental health care services for children in BC
Not all mental health professions are regulated in BC
What is mental illness?
Mental illness, physical illness, and suicide
Mental illness is debilitating
Childhood mental illness
Mental illness, trauma, and homelessness
Children's mental health before 2020
Children's mental health during the COVID-19 pandemic
More than twenty years of expert appeals
What have we done in BC?
Mental illness is expensive
Families and society pay for childhood mental illness
Economic benefits of investing in mental health
Benefits of investing in children's mental health
Children's rights are Canadian law
Here's what we can do
Sample Letter to an MLA
References
How Do You Care For a Sick Child?
Have you ever cared for a child when they were sick? Do you remember how it felt to watch them suffer? Most parents and caregivers have experienced the fear, worry, anger, and even aggression that come up when their child’s health or safety is threatened. There is no more powerful feeling than the instinct to protect our children.
When a child is sick, most adults will do their best to help. We offer comforting words, hugs, hot soup, and medicine. But when a child has a serious illness, we take them to see a health care professional such as a doctor. Serious illnesses should be treated by a professional because they can affect the child’s growth, their learning, and their future. Untreated illnesses can have lifelong consequences or even threaten a child’s life. So what would you do if you could not access health care services for your child?
Today, there is a grave threat to the children of BC, Canada, and the world.
Mental illness.
Despite advances in the field of mental health, and many appeals by world-leading experts, many children still cannot access the mental health care they need. Furthermore, children do not have the same ability as adults to advocate for themselves and their needs. Similarly, during the inclusive education movement in the 1960s, it was up to the families and professionals who serve children to advocate on their behalf to a government that was slow to recognize the rights of children (source 1, source 2).
Access to mental health care is critical for ensuring our children’s healthy development, as well as the future stability of our society. When childhood mental illness and trauma go untreated they do not go away. Instead, they transform into more serious, and expensive, problems such as serious mental illness in adulthood, inability to work, substance use, homelessness, life-threatening health conditions, and suicide. This is why early intervention is so important for children and for Canada.
Right now, in BC, universal health care does not cover many services, waitlists for public services are months long, and private services are unaffordable for many families. Even the most accessible and affordable service for children, the school counsellor, is limited by systemic barriers which reduce their access to children.
Therefore, we must direct our protective instinct towards advocating for guaranteed access to mental health care for our children.
1. Mental Health Care In Canada
"I came to believe that health services ought not to have a price tag on them, and that people should be able to get whatever health services they require irrespective of their individual capacity to pay." (source)
Tommy Douglas, 7th Premier of Saskatchewan (1944-1961)
Canadians have access to universal health care, which covers any “medically necessary health care services provided on the basis of need, rather than on the ability to pay” (source).
In Canada, the most vulnerable people are treated the same as everyone else, regardless of their age, background, or income. This was not the case before 1984. After decades of advocacy, the Government of Canada finally signed the Canada Health Act, which guaranteed universal health care for all (source):
It is hereby declared that the primary objective of the Canadian health care policy is to protect and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers. (source)
Today, universal health care is a matter of pride and national identity for Canadians (source 1, source 2). Despite its existence, universal health care does not cover all mental health care services. Barriers exist in the mental health care system, financial and otherwise, that prevent people from accessing services.
Section 1 explores the mental health care system, some of the services that exist for children, and several notable barriers to access.
1.1 There are Many Kinds of Mental Health Care Services
Mental health and physical health are both covered by the Canadian health care system. mental health professionals include counsellors, psychiatrists, psychiatric nurses, psychologists, psychotherapists, social workers, and more. In Canada, visits to a doctor (if you have one), visits to the hospital, visits to a psychiatrist, and some medications for mental illnesses are covered by universal health care. However, visits to other professionals, such as counsellors or psychologists, are not covered. Why?
The Health Care Act covers “medically necessary [emphasis mine] health care services.” Hospitals are staffed by medical professionals. Psychiatrists and psychiatric nurses are both medical professionals who have specialized in mental illness. Therefore, these services are covered. However, many people seek help through a counsellor or other mental health professional before they ever see a psychiatrist or visit the hospital. Costs for services that are not covered by universal health care must be paid out-of-pocket or by extended health care benefits (private insurance).
Strangely, The Government of Canada (GOC) webpage on anxiety and mood disorders suggests that “health professional” includes psychologists, social workers, counsellors, and psychotherapists (see Figure 1). This official publication provides also states “professional care is essential [emphasis mine] in the management of mood and anxiety disorders” (source). So, according to GOC, mental health care is essential, but apparently not medically essential, given that the professionals they have listed are not covered by universal healthcare. This inconsistency is one, small demonstration of the larger problems that exist in the mental health care system in Canada.
Figure 1
Percentage of those with mood and/or anxiety disorder(s), 18 years and older, who consulted a health professional (by type) about their disorder(s) in the past 12 months, Canada (excluding territories), 2013 (source)
1.2 Mental health care Services for Children in BC
Mental health care services for children include both public and private services. Public services include visits to a family doctor, the hospital, Child & Youth Mental Health (CYMH), and school counsellors, among others. Private services include counsellors, psychologists, and others who specialise in working with children and may own a private practice or work through an agency.
(NOTE: I have left out some services for brevity. The care they provide is valuable, yet a comprehensive overview is beyond the scope of this article.)
1.2.1 Public Services: Child & Youth Mental Health
Child & Youth Mental Health (CYMH) offers free mental health care services for all children in British Columbia and is run by the Ministry of Children and Family Development (MCFD). There are 100 CYMH clinics across the province, each staffed by a team of mental health professionals including counsellors, psychologists, psychiatrists, and others. These teams provide effective and high-quality mental health care. Data collected by MCFD shows that clients who access CYMH are overwhelmingly satisfied with their services (source).
CYMH serves children under the age of 18 who are experiencing “Significant difficulties related to their thoughts, feelings and behaviours” (source). In other words, not all children are eligible for service.
There are also other services that are connected to CYMH, including Ledger House in Victoria and the Maples Adolescent Treatment Centre in Coquitlam. Both these centres provide intensive, in-patient interventions for children with complex mental health needs. In other words, few children are eligible for service.
As the demand for child mental health care services has risen in recent years, so have the waitlists for CYMH. In some cases, children with mental health challenges in British Columbia may have to wait six months or more to receive treatment (source). However, this is not a new problem, as concerns about waitlists have appeared in government publications and the news since at least 2013 (source 1, source 2).
In 2019, the Ministry of Mental Health and Addictions stated “We know the services needed to address these challenges aren’t keeping pace with needs” (source). In response to this gap, efforts have been made to expand services, including the development of Integrated Child & Youth (ICY) teams (source). Currently, ICY teams exist in only a handful of regions of BC.
The main barrier to accessing CYMH is long wait times caused by underfunding and understaffing. Improving access to CYMH requires increasing capacity. This means hiring more mental health professionals to meet the needs of children and families.
1.2.2 Public Services: School Counsellors
In BC, school counsellors are both certified teachers and hold a Master’s degree in counselling psychology or a related discipline. They are qualified, frontline mental health professionals who work inside the schools to meet the needs of all students.
School counsellors have a combination of experience and training which includes child development, ethics and legal standards, mental health and mental illness, the theory and practice of counselling/psychotherapy, the theory and practice of education, trauma-informed practice, and other areas.
School counsellors play a critical role in both the mental health care system and the school system. As the only mental health professional inside the school, they are uniquely prepared to implement the BC Ministry of Education’s “Mental Health in Schools Strategy”. They may coordinate mental health promotion in schools through mental health literacy and social-emotional learning programmes (e.g. EASE). They can also train school staff in Trauma-Informed Practice, helping children recover from the negative impacts of adverse childhood experiences (ACEs) and trauma.
Early intervention and mental illness prevention are a central part of a school counsellor’s scope of practice. This includes providing individual and group counselling services, risk assessment for suicide and violence, case detection for children showing signs of mental illness, collaboration with mental health services outside the school (e.g. CYMH), crisis intervention, and identifying and reporting child abuse and neglect.
An essential element of a school counsellor’s services is working with families - writing referrals for mental health services, connecting families to community-based supports (e.g. neighbourhood houses, transition houses), and coordinating public education for families (e.g. workshops on anxiety or grief and loss).
Why does any of this matter?
Because every child can access a school counsellor, regardless of their background. Since they work inside the school building, children and families know where to access services, and the services are positioned where children spend most of their week. Furthermore, their services are free. Nevertheless, there are barriers which limit the accessibility of school counsellors to children.
Every school district has a different “Collective Agreement” with the Ministry of Education. This agreement decides, among many things, the ratio of students to school counsellors. The provincial ratio (which is the same as in Victoria) is 693 students to 1 school counsellor (source). However, in some districts, such as Surrey, the ratio is as high as 965 to 1 (source). These ratios were determined more than 20 years ago and simply do not meet the needs of the students (source). Furthermore, these ratios also do not fit with research evidence and standards determined by qualified authorities.
The American School Counselor Association (ASCA) recommends a 250 to 1 ratio (source). Research shows that small ratios support students’ academic performance, attendance, and graduation rates (source 1, source 2, source 3). Schools with smaller ratios also record less conduct and discipline issues (source). The effects that smaller ratios have on these outcomes are also more pronounced in high-poverty areas (source).
Higher ratios mean higher caseloads for school counsellors, and reduced access for every student. Most elementary and rural schools in BC have a population of less than 693 students. In these schools, school counsellors are employed less than five days per week, in proportion to the Collective Agreement ratio. Because the school counsellor is not at the school every day, they are even less accessible.
Some school districts provide school counsellors with additional, non-counselling duties, such as managing Individual Education Plans (IEPs). These non-counselling activities take time away from counselling services, further reducing access to qualified mental health care for students. Research evidence shows that students benefit most when school counsellors are able to dedicate most of their time to providing counselling services (source).
Inadequate staffing is not only an issue for school counsellors, but part of a much bigger problem. There is a critical teacher shortage in BC, which is the result of chronic underfunding, years of cuts, and high rates of teacher burnout (source 1, source 2).
The main barrier to accessing school counsellors are outdated ratios and inconsistent policies delegating non-counselling duties. Both reduce the time school counsellors are available to children. Improving access requires reducing ratios, hiring more school counsellors, and maximizing their time spent on providing counselling services.
1.2.3 Private Mental health care Services
There are thousands of private mental health professionals in BC, including counsellors and psychologists who specialize in working with children. Most services start at $135 per hour (source). As explained previously, these services must be paid for out-of-pocket or by extended health care benefits, which not all families have. Additionally, some extended benefit packages still do not cover all mental health care services.
Therefore, cost is the main barrier for most families. Since poverty is known to have a negative influence on children’s mental health and development (source), the financial inaccessibility of private mental health care in BC disproportionately affects the most vulnerable children.
Improving access to private services requires reducing costs. Ideally, all mental health care services for children would be free and covered by universal health care. Realistically, extending provincial health care to include counselling as an eligible service may achieve similar ends.
1.3 Not all Mental health care Professions are Regulated in BC
Barriers to accessibility exist at both the public and private levels of mental health care. There are also barriers that exist at the level of provincial policy.
“Currently, anyone in BC can claim to be a counsellor, regardless of qualifications, competency, or experience. This places BC residents in vulnerable and potentially dangerous situations” (source). The reason for this concerning situation is that the policies regulating mental health professions are inconsistent in BC.
There are 26 regulated health professions in BC, ranging from dentistry and massage therapy to surgeons and psychiatrists (source). When a profession is regulated, a regulatory body (i.e. a “college”) is made to protect the public. Regulatory bodies define the scope of practice of the profession and oversee the standards for competence, ethics, and training of their professional members. The title of the profession is also “protected,” which means that titles such as “dentist” or “massage therapist” can only be used by people who qualify for registration with the regulatory body. Finally, members of the public can file complaints with the regulatory body who can then discipline professional members.
Many mental health care professions, such as psychiatrists, psychologists, and social workers, are regulated in BC. (CPSBC, CPA, BCCSW). However, counselling and psychotherapy are not regulated in BC, even though they are in some other provinces (source). Lack of regulation has meant that, in at least two notable cases, incompetent and unethical practicioners may have abused clients with little transparency or consequences (source 1, source 2).
Most counsellors and therapists in BC voluntarily seek certification through the BC Association of Clinical Counsellors (BCACC) or the Canadian Counselling and Psychotherapy Association (CCPA). Like a regulatory body, these organizations require members to meet and maintain standards of ethics, professionalism, and training. This is good news for the public, who can rest assured that Registered Clinical Counsellors (“RCCs”) and Canadian Certified Counsellors (“CCCs”) meet these standards.
Although the BCACC and CCPA can investigate complaints against members and follow-up with disciplinary actions, they cannot make any of this public. Since there is no regulation in BC, these associations also have no ability to oversee non-members or discipline members who choose to leave.
Efforts to regulate counselling therapy in BC have been repeatedly hindered by a lack of political commitment. Now, during the COVID-19 pandemic, a growing mental health crisis has elevated the need to regulate counselling therapy in BC.
1.4 Summary
The Canadian mental health care system includes both public (e.g. CYMH, school counsellors) and private services for children. Barriers to access exist at all levels, which are preventing children from getting the care they need.
These barriers exist due to a lack of understanding about the reality of mental illness.
2 Understanding Mental Illness
"One way to ensure that our health system meets children's mental health needs is to move toward a system that balances health promotion, illness prevention, early detection, and universal access to care… Children and families are suffering because of missed opportunities for prevention and early identification, fragmented services, and low priorities for resources. Overriding these problems is the issue of stigma, which continues to surround mental illness." (source)
Dr. David Satcher, Former Surgeon General of the United States, 2000
The stigma that mental illnesses are not “real” illnesses remains prevalent around the world and has had significant effects on policy, resulting in service deficits and a lack of commitment to addressing mental illness (source).
Stigma has effects on individuals as well. For instance, stigma prevents many people with mental illnesses from seeking help (source).
An effective way to reduce stigma and its negative effects is to learn about mental illness and share your understanding with others (source). Therefore, Section 2 explores the reality of mental illness, its connection to physical health, and its effects on children, families, and society.
2.1 What is Mental Illness?
Mental illnesses are diagnosable illnesses that affect a person’s behaviours, emotions, thinking, and relationships (source 1, source 2). Although most mental illnesses are “invisible,” they are, in reality, common. Worldwide, more than half the population in middle-to-high income countries will suffer from mental illness at some point in their lives (source). In Canada, roughly 1 in 5 people are affected by mental illness each year (source).
Anxiety and mood disorders are the most common mental illnesses. This is illustrated by the fact that 28.8% of adults will develop an anxiety disorder and 20.8% of adults will develop a mood disorder at some point in their lives (source). In Canada, 3 million Canadian adults were affected by anxiety and mood disorders in 2015, and this number is expected to rise to nearly 9 million by 2041 (source).
Other diagnosable mental illnesses include eating, obsessive-compulsive, personality, psychotic, substance use, and traumatic stress disorders (source). Two key features that all mental illnesses share in common is that they are distressing and they impair a person’s ability to function.
2.2 Mental Illness, Physical Illness, and Suicide
Recall the last time you had a physical illness or injury. You may have behaved, felt, thought, and even related to others differently. This is because there is a connection between physical and mental health, and impairment in one area can affect the other.
This connection goes both ways—mental illnesses can also affect your physical health. For instance, it is common for people experiencing mental illnesses to have physical illnesses as well. This is called “comorbidity.”
The physical health consequences of mental illness can also be life-threatening. In 2006, researchers in Ohio investigated the cause of death for 600 patients in a psychiatric hospital. The patients died at a much higher rate than the general population from cancer, chronic respiratory disease, diabetes, heart disease, influenza, stroke, and pneumonia (source).
Overwhelming research evidence shows that anxiety disorders, mood disorders, and schizophrenia all have significant negative effects on physical health, such as increased risk of heart disease (source 1, source 2, source 3).
People suffering from depression, schizophrenia, and substance use disorders are at a dramatically increased risk of early and unnatural death, especially due to suicide (source 1, source 2, source 3). Suicide is one of the leading causes of death among people younger than 18 in Canada and it is the second leading cause of death among 15-29 year-olds worldwide (source 1, source 2). In BC, an average of 21 children aged 10-18 committed suicide every year between 2008-2020 (source 1, source 2). Evidence shows that the majority of people who die by suicide have had a diagnosable mental illness at some point prior to death (source).
The suffering and disability caused by mental illnesses, and the impact this has on physical health, can also affect a person’s ability to function in everyday life.
2.3 Mental Illness is Debilitating
At work, mental illnesses are highly disabling, which has significant effects on a person’s ability to work, complete school, and fulfil family duties. In Canada, mental illness is one of the leading causes of disability, affecting more than 7 million working age adults (source). This has consequences both for individuals and for the economy. For instance, one third of Canadians with an anxiety or mood disorder reported they stopped working altogether in the year 2015 (source).
Research in Australia, Canada, and the United states show similar findings: people with mental illnesses are more likely to miss work (“absenteeism”), to have less productivity at work (“presenteeism”), to work fewer hours, to stop working altogether, to retire early, and to obtain lower levels of education (source 1; source 2; source 3; source 4). Of course, this makes sense. Do people with serious physical illnesses always show up for work? Do they work as effectively when they are sick? No.
Mental illness also has debilitating effects on children.
2.4 Childhood Mental Illness
The majority of mental illnesses affecting Canadians begin in childhood and adolescence and can be identified before the age of 25 (source 1, source 2, source 3, source 4). Childhood mental illness takes an immense toll on families; the education, health care, and justice systems; and the economy (source 1; source 2).
Although the economic cost of childhood mental illness is high, the cost in terms of human suffering is much greater. For children, mental illnesses affect their wellbeing, their learning at school, their relationships with family and friends, and their growth (source 1, source 2, source 3, source 4, source 5, source 6).
Traumatic experiences can also have a profound effect on children (source 1, source 2, source 3). For example, some of the long-term effects of adverse childhood experiences (ACEs) include cancer, chronic lung disease, depression, heart disease, liver disease, severe obseity, substance use disorders, and suicide (source). In short, ACEs and traumatic experiences can have significant, negative effects on both physical and mental health, and reduce life expectancy.
Mental health is critical for children’s learning (source). Research shows that children who have poorer mental health and those who have been exposed to traumatic experiences also experience lower school success and academic engagement (source 1, source 2). These effects persist into young adulthood, as mental illnesses have also been shown to have negative effects on academic success in college students (source).
Fortunately, childhood mental illness and trauma are both treatable. Research has identified numerous effective methods for promoting mental health, preventing mental illness, and treating mental illness in children (source 1, source 2, source 3, source 4, source 5). There are also a number of effective ways to help children recover from the effects of traumatic experiences and ACEs (source 1; source 2).
However, untreated childhood mental illness and trauma can have devastating, lifelong consequences and even threaten a child’s life (source 1, source 2, source 3, source 4).
As children with untreated mental illnesses grow up, they are at a much higher risk for developing additional disorders in adulthood (source). For instance, substance use disorders, which most commonly begin in later adolescence, are often related to impulse-control or anxiety disorders earlier in childhood (source). Furthermore, there is a profound connection between childhood mental illness, trauma, substance use, and homelessness.
2.5 Mental Illness, Trauma, and Homelessness
Untreated childhood mental illness and trauma have a significant influence on a person’s likelihood of experiencing homelessness in adulthood (source 1, source 2, source 3).
The documentaries Through a Blue Lens and Bevel Up: Drugs, Users, and Outreach Nursing feature the lives of unhoused people living on Vancouver’s Downtown Eastside. In these films, many of the people interviewed had experienced ACEs such as abuse and neglect.
Research shows that ACEs are substantially overrepresented among unhoused people (source 1, source 2). Although there is no single “cause of homelessness” (source), the relationship between untreated childhood trauma, mental illness, substance use, and homelessness has become a topic of increasing focus in Canada in recent years (source 1, source 2, source 3). Research shows that mental illnesses and substance use disorders are substantially more common among people experiencing homelessness (source 1, source 2, source 3, source 4, source 5, source 6). This is unsurprising, considering the effects of ACEs mentioned above and the high incidence of ACEs among unhoused people.
If homelessness is often the downstream result of childhood mental illness and trauma, and many unhoused people experience mental illnesses, then why not invest in early interventions that can reduce the incidence and impact of ACEs, trauma, and childhood mental illness? Why not prevent more serious, and expensive, problems before they happen?
2.6 Summary
Mental illness and trauma can have profound, negative effects on children. Untreated, these problems can have lifelong consequences, causing harm and impairment into adulthood. There is a grave need to address children’s mental health in BC.
This begs the question: Are the children in BC doing alright?
3 The Children’s Mental Health Crisis
"Crisis: (1) the turning point in a disease; (2) the decisive moment, especially in a tragedy; (3) a time of danger or suspense in politics."
Webster’s Canadian Dictionary
For at least 20 years, governments and researchers have voiced concerns about a growing children’s mental health crisis. The Coronavirus Disease (COVID-19) pandemic has worsened this existing problem. Today, we are at a turning point when the decisions we make, individually and collectively, may lead to change for the better or for worse.
Section 3 describes the state of children’s mental health before and after the COVID-19 pandemic began, as well as a limited selection "of appeals by experts in children’s mental health from 2000 until present.
3.1 Children’s Mental Health Before 2020
In 2015, the Mental Health Commission of Canada (MHCC) conducted a comprehensive study of mental health in Canada (source). Their research highlighted several of the core issues described in this article, including lack of access to mental health care, the effects of stigma, and the impairment caused by mental illness. Some of the areas of significant concern they identified included:
Discrimination experienced by people with mental health conditions;
High numbers of children who are vulnerable in at least one area of child development;
High numbers of youth (ages 12-19) seriously considering suicide;
High suicide rate among youth (ages 12-19), adults, and seniors;
Low employment among people with common mental health conditions;
Low self-rated mental health and sense of belonging among people with common mental health conditions; and
Unmet needs for mental health care and general health care among people with mental illnesses (source).
In the United States of America, a study was conducted with approximately 2-4 million children between the ages 4-17 in the years 2012-2018. This study identified that rates of eating disorders increased by 96%, anxiety disorders by 95%, and mood disorders by 73% in those years (source). The researchers state that these increases can only be partially explained by changes in attitudes toward mental illness and diagnosis—the rest of the change is a real increase in the rates of these diagnosable illnesses.
In 2013-2018, The McCreary Centre Society conducted a survey with students in the BC school system. The study reported increases in panic attacks, post-traumatic stress, self-injury, sexual abuse and harassment, and serious consideration of suicide (source). In 2019, just 6 months before the pandemic began, the BC Ministry of Mental Health and Addictions responded to the McCreary survey, stating “the trend that should make all of us take notice is the growing number of children and youth experiencing challenges” (source).
Together, these publications show that there were already serious concerns about children’s mental health identified internationally and locally years before the COVID-19 pandemic began.
3.2 Children’s Mental Health During the COVID-19 Pandemic
The COVID-19 pandemic has negatively affected the mental health of Canadians (source). The impacts of the pandemic are expected to be both serious and long-lasting. However, some groups of people have been affected more than others.
Starting in March 2020, the mental health of children and seniors declined steeply. Since October 2020, children’s mental health has continued to decline, while seniors have been improving. By December 2021, people under the age of 18 in Canada reported they were drinking more alcohol, experiencing greater anxiety and depression, and were more likely to be seriously contemplating suicide than at the beginning of the pandemic (source).
Many children have also lost a primary caregiver during the pandemic. A child’s relationship with their primary caregivers is essential for mental health and the death of a caregiver can have lifelong consequences for the child (source 1, source 2; source 3).
A study conducted in 21 countries between March 2020 and October 2021 estimated that a minimum of 3.3 million children have been orphaned and 3.5 million have lost their primary caregiver due to COVID-19 (source). In a recent press release, the United States Centres for Disease Control and Prevention stated that more than 140,000 American children have lost a primary caregiver due to COVID-19 in the United States (source). In Canada, it is estimated that a minimum of 2,000 children have been orphaned and 2,300 children have lost a primary caregiver to COVID-19 (source). These losses may have long-term effects on the mental health of a whole generation of children.
Although not all children have lost a caregiver, they are all experiencing the impacts of chronic stress due to COVID-19. Researchers have identified that the stress of the pandemic has had impacts significant effects on children’s mental health (source). Furthermore, they anticipate long-term consequences which include altered stress hormone sensitivity, mental illness, substance use, and suicidal thoughts.
Right now, and in the years ahead, the governments of Canada and British Columbia must take action to care for the mental health of children as part of their COVID-19 pandemic response.
3.2 More Than Twenty Years of Expert Appeals
Also long before COVID-19, world-leading experts in children’s mental health were appealing to governments and the public to address the growing crisis.
In 2000, the U.S. Surgeon General’s Conference Report called children’s mental health a “national priority.” It states:
The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illnesses in youth. (source)
In 2005, research by the American Medical Association showed that most mental illnesses have their first onset in childhood or adolescence. The researchers stated:
Given the enormous personal and societal burdens of mental disorders, these observations should lead us to direct a greater part of our thinking about public health interventions to the child and adolescent years and… to focus on early interventions aimed at preventing the progression of primary disorders and the onset of comorbid disorders. (source)
In 2006, the Senate of Canada Standing Committee on Social Affairs, Science, and Technology published “Out of the Shadows At Last,” Canada’s first national report on mental health. They stated:
Children and youth are at a significant disadvantage when compared to other groups affected by mental illness, in that the failings of the mental health system affect them more acutely and severely. The Committee believes it is imperative to move aggressively to tackle key problems now.
The importance of early intervention cannot be overstated. When the first symptoms of distress or illness appear in a young person, regardless of age, family caregivers, health professionals, and educators should intervene immediately. (source)
In 2011, the Mental Health Commission of Canada (MHCC) found that childhood mental illness is a strong risk factor for mental illness in adulthood. The researchers stated:
The high relative risks associated with the transitions from childhood to adolescence and adolescence through to adulthood highlight the important role of early identification and treatment in potentially reducing the likelihood of subsequent mental illness later in life. (source)
In 2012, the Mental Health Commission of Canada developed “Changing Directions Changing Lives,” the first Mental Health Strategy for Canada. They stated:
Healthy emotional and social development lay the foundation for health and resilience in childhood and throughout life. Despite more than a decade of research that shows the benefits of mental health promotion and mental illness prevention throughout childhood, Canada does not do enough. (source)
In 2016, an international research team investigated effective mental health interventions. They stated:
Although much attention has historically been paid to the health sector for the delivery of mental health services, greater consideration of interventions at the population- and community-levels are necessary, particularly for the delivery of mental health promotion and prevention interventions, as well as for the early identification of mental disorders especially in children and adolescents, and to a lesser degree, care and rehabilitation. (source)
In 2019, the BC Ministry of Mental Health and Addictions published “A Pathway to Hope,” a mental health strategy for BC. It states:
Our major focus is on child and youth mental health. When we improve their mental wellness and address small problems before they become bigger, we are making lasting investments in making B.C. better for everyone.
The neglect of promotion, prevention, and early intervention services has contributed to a downward trend in the social and emotional development of young children. After so many years when so little was done, B.C. isn’t prepared or able to provide equitable access to trauma-informed, culturally safe, and person-centered care when young people and their families need it. (source).
Finally, in 2021, the United Nations Children’s Fund (UNICEF) dedicated the “State of the World’s Children” address to the issue of children’s mental health. It states:
The COVID-19 pandemic represents merely the tip of the iceberg when it comes to poor mental health outcomes. It is an iceberg we have been ignoring for far too long, and unless we act, it will continue to have disastrous results for children and societies long after the pandemic is over.
We can wait no longer. We cannot fail another generation. The time to act is now.
Governments and societies are investing far, far too little in promoting, protecting, and caring for the mental health of children, young people, and their caregivers. (source)
The common message among each of these statements is this:
We must address children’s mental health through mental health promotion, mental illness prevention, and early intervention, and we must act now.
3.4 What Have We Done In BC?
In the past decade, large-scale efforts have been made toward addressing children’s mental health in BC. These include erase, Mental Health in Schools, and A Pathway to Hope, not to mention the tireless efforts of the people who work in education, child mental health, and related fields. Clearly, we do not lack creative, committed, and effective professionals.
We also do not lack infrastructure—there are 100 CYMH clinics and a well-functioning school system within which child mental health professionals can do their work. There are also numerous private mental health care providers.
We also have an abundance of research on effective, evidence-based mental health promotion, mental illness prevention, early intervention, and treatment approaches for mental illness and trauma (source 1, source 2, source 3, source 4, source 5, source 6).
Availability is not the problem. Access is the problem. As described in Section 1, there are barriers that prevent access to mental health services for children. These barriers include underfunding and understaffing of public services, outdated school counsellor ratios, and affordability of private services.
3.5 Summary
For more than twenty years, there has been a building children’s mental health crisis that the COVID-19 pandemic has made worse. Despite numerous appeals by experts in children’s mental health, little commitment has been made to addressing the barriers that are preventing children in BC from receiving mental health care.
The time to act is now.
The cost of neglect is far greater than the cost of care.
4 The Cost of Mental Illness
"Most of the mental health disorders affecting Canadians today begin in childhood and adolescence. Failure to recognize this fact leads us to dealing with stage-four cancer, often with major secondary effects, instead of a stage-one or stage-two disease. Mental health issues, if not addressed early in life, threaten to bankrupt our health care system." (source)
Dr. Diane Sacks, Former President of the Canadian Paediatric Society, 2005
Making a commitment to children’s mental health is an investment. The moral rationale for this investment is straightforward; however, an economic rationale is also necessary. When policy makers commit to making such an investment, they need to know they are using public funds wisely.
Part 4 describes the current costs of mental illness globally and in Canada, as well as the expected economic and social benefits of investing in children’s mental health.
4.1 Mental Illness is Expensive
Economic decisions in health care are often based on life expectancy and mortality statistics. Although mental illnesses contribute greatly to physical illness and can be fatal, death certificates are unlikely to read “depression and post-traumatic stress disorder.” Instead, they are more likely to read “heart disease,” even if the former is more accurate. As a result, life expectancy and mortality data inaccurately capture the real impact of mental illness (source). However, other measurements do offer insight into the cost of mental illness, such as the economic burden on the health care system, lost work productivity, and lost economic growth.
Worldwide, the total cost of mental illness in the year 2010 was estimated to be between $2.5 Trillion and $8.5 Trillion US Dollars (USD) (source). This cost is greater than cancer or diabetes and is comparable to heart disease, the leading cause of death worldwide (source). Furthermore, the cost is expected to double by 2030.
In Canada, the most conservative estimates show the total cost of mental illness in the year 2011 to be roughly $42.3 Billion Canadian Dollars (CAD). For context, the total health expenditure for Canada was $200 Billion CAD in 2011 (source). By 2041, the cost of mental illness in Canada is expected to be greater than $185 Billion CAD, including adult and childhood mental illnesses (source).
Because mental illness is so debilitating (see Section 2.3) the workforce is also affected. In 2012, mental illness cost Canadian employers approximately $20.7 Billion CAD (source). Furthermore, more than $9 Billion is spent each year on disability benefits for workers experiencing mental illness (source). In short, when Canadians are unhealthy, then the workforce is also unhealthy.
Some of the costs of mental illness are also borne by the justice and social welfare systems. Homelessness generates tremendous economic costs in these systems as well as in health care. In 2016, the annual cost of homlessness in Canada was estimated to be $7 Billion CAD (source). In 2017, a Canadian study found the annual cost of a single person experiencing homelessness to be approximately $59,000 CAD (source).
4.2 Families and Society Pay for Childhood Mental Illness
Childhood mental illness is tremendously costly. Worldwide, it is estimated to cost $387.2 Billion USD each year (source). This cost is also expected to increase to $420 Billion USD by the year 2040 if nothing is done to address the growing children’s mental health crisis.
Families also pay. “When a child or a young person lives with mental illness or addiction (sic), so too do [their] family caregivers” (source). In some cases, caregivers and parents must take time off work, or stop working altogether, to support their child(ren). Because not all mental health care services are covered, the costs for care may fall directly on the family.
As parents and caregivers must often take time off work to care for their children experiencing mental illness, the economy also suffers. Research conducted in Ontario estimated that the provincial economy lost $421 Million CAD in a single year as parents took time off to care for their children struggling with anxiety (source). This limited data does not account for the costs borne directly by the family to pay for treatments, medication, and other expenses.
Certain childhood mental illnesses are more “expensive” than others. For instance, a single child with conduct disorder who does not receive treatment may generate lifetime costs as high as $1.5 Million USD (source). Research from the United Kingdom (UK) found that adults who had been diagnosed with conduct disorder during childhood produced 18 times greater costs for the justice system (source).
The long-term costs of childhood mental illness are also great. The results of a 25-year study in the United States found that adults who had experienced mental illness during childhood earned on average $10,400 USD per year (source). This translates to approximately $300,000 USD of lost family income across a lifetime.
4.3 Economic Benefits of Investing in Mental Health
Enhancing the capacity of the BC mental health care system to meet the needs of children will cost money. Therefore, it is important to understand the expected economic benefits of investing in children’s mental health.
Research shows that community-based (i.e. outside the hospital) and primary care mental health services are both effective and cost-effective (source). Primary care mental health services are the “first point of contact” services, which include school counsellors for children.
In the world of money, return on investment (ROI) analyses are a simple way to measure whether an investment is worthwhile or not. In the world of mental health, ROI excludes the personal, familial, and social benefits of intervention.
In 2016, a team of researchers conducted a ROI analysis for studies around the world that measured the costs and economic benefits of anxiety and mood disorder treatments with adults. The researchers estimated the ROI for increasing treatment coverage for these disorders was between 2.3 and 5.7 (source). This means that every $1 spent on enhancing capacity to treat anxiety and mood disorders in the population can be expected to produce an economic benefit of $2.3 to $5.7.
For substance use disorders, often the downstream effect of childhood mental illness (source), mental health interventions have also shown high ROIs. The US National Institute on Drug Abuse states that every $1 spent on treatment programs results in a return of $4 to $7 to the justice system. (source). When health care savings are included, the return jumps to $12.
These high ROIs, from 2.3 to 12, provide a clear economic incentive for investing in enhancing the capacity to treat anxiety, mood, and substance use disorders. What if these downstream effects could be prevented from occurring in the first place through early intervention?
4.4 Benefits of Investing in Children’s Mental Health
Since most mental illness begins in childhood and can be identified before age 25 (source 1, source 2, source 3), early intervention can be expected to reduce the costs of mental illness on families and society (source). Furthermore, early intervention may prevent the onset of more serious, and expensive, problems in adulthood. This means the economic benefits of early intervention continue as a child ages.
Research suggests that children’s health is a valuable economic investment. However, the ROI can only be measured over the long-term. Since children grow over a course of years and decades, the benefits of early intervention may only be visible much later. Likewise, the effects of neglecting a child’s mental health also appear over the course of many years (source). Some of these downstream effects are extremely expensive.
Substance use in adolescence is a common downstream effect of conduct disorder (source). Therefore, treating and preventing conduct disorder may have significant economic benefits. Researchers in the UK found that providing early intervention for a single child with conduct disorder results in a lifetime savings of $365,000 CAD (source). If early intervention programs could prevent just 10% of the cases of conduct disorder in Canada, this could amount to more than $3 Billion CAD in savings to the health care and justice systems. Fortunately, there are a number of evidence-based methods to prevent and treat conduct disorder in children (source).
A study was conducted with 5,000 American families on the long-term costs of childhood mental illness. The researchers concluded, “Effective treatments targeted to children that lower the risk of experiencing these conditions or mitigate their adult consequences are likely to [produce] long-lasting payoffs and to be very cost-effective” (source). In relation to these findings, the Mental Health Commission of Canada states that improving a single child’s mental health from moderate to high results in a lifetime savings of $140,000 CAD (source).
Effective early interventions for children can also generate long-term benefits for society. Parents and caregivers experience less emotional and financial strain when their children are healthy, which in turn can mean better mental health for the whole family. As children grow up, those with better mental health can be expected to experience more school successes. Eventually, these children will grow into young adults who enter into the workplace. As workers, they contribute more to the economy as they are more present at work, more productive at work, and return to work quicker after taking leave for their health (source 1, source 2).
Some day, these young adults may start families of their own. Mentally healthy adults spend more years of their life in a state of physical health and their risk of illness, early death, and suicide is much less. As parents and caregivers, mentally healthy people are more likely to contribute to household duties and to participate in community organizations and local efforts. Finally, these people generate much lower costs for the health care, justice, and social welfare systems (source 1, source 2).
4.5 Summary
Mental illness creates an extremely high economic burden on families and on society and costs are expected to increase in the years ahead. Research indicates that mental health interventions produce a high return on investment, and early interventions that prevent the onset of more serious problems can have significant economic and social benefits. Removing barriers to access will benefit the economy, support a healthy workforce, and keep Canada competitive globally.
For the stability of our economy and society, guaranteeing that every child has access to mental health care is imperative.
5 Every Child Has the Right to Life
"We compel children to shoulder humankind’s responsibilities tomorrow, but give them none of the human rights today. Were humanity divided into adults and children, and life into childhood and adulthood, we would discover that the child occupies a very large part of the world and of life. But we are incapable of seeing the child, just as we earlier could not see women, oppressed social groups, and oppressed peoples." (source)
Janusz Korczak, 1929, “The Child’s Right to Respect”
5.1 Children’s Rights are Canadian Law
Janusz Korczak’s early efforts towards children’s rights inspired many, and in 1989, the Convention on the Rights of the Child (CRC) was created (source).
The CRC is an international treaty that describes the rights of all children. Canada ratified the CRC in 1991, which makes it an official part of Canadian law. This means that the Government of Canada and all its institutions (e.g. education, health care, justice, etc.) must uphold the rights laid out in the CRC (source).
Several articles in the CRC are directly relevant to children’s mental health and the purpose of this article: “Guarantee Access to Mental health care for Every Child.” The CRC states:
Article 3.1: In all actions concerning children… the best interests of the child shall be a primary consideration.
Article 3.3: [Governments] shall ensure that the institutions, services, and facilities responsible for the care or protection of children shall conform with the standards established by competent authorities, particularly in the areas of safety, health, in the number and suitability of their staff, as well as competent supervision.
Article 6.1: [Governments] recognize that every child has the inherent right to life.
Article 6.2: [Governments] shall ensure to the maximum extent possible the survival and development of the child.
Article 24.1: [Governments] recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.
Article 29.1: [Governments] agree that the education of the child shall be directed to: (a) the development of the child’s personality, talents, and mental and physical abilities to their fullest potential. (source)
If we are to uphold Article 3.1, then the decisions we make today must be in the best interests of children. If we know that BC lacks access to mental health care, that childhood mental illness has terrible effects on children, and that there is an ongoing children’s mental health crisis, then the decisions we make today should be toward promoting, protecting, and caring for children’s mental health. We need to remove barriers to access. We need to increase the capacity of public services to meet children’s mental health needs.
If we are to uphold Article 3.3, then we must ensure that the public services for children (e.g. CYMH, the school system) meet standards for safety, health, number and suitability of staff, and supervision. Right now, there are not enough staff to meet the mental health needs of children. We need to hire more qualified mental health professionals, and to ensure such new hires meet standards for competence, it is imperative that policies be put into action to regulate counselling therapy.
If we are to uphold Articles 6.1 and 6.2, then we must protect children’s life, survival, and development to the maximum extent. Mental illness is a threat to children’s development and their life (see Section 2.2). We need to ensure children receive the mental health care they need.
If we are to uphold Article 24.1, then we must ensure the facilities for the treatment of mental illness and rehabilitation of mental health are accessible to children. We need to ensure that care is readily available when they need it and where they are - in their homes, communities, and schools.
If we are to uphold Article 29.1, then we must ensure that children’s mental health is supported within the school system itself. We need to ensure there is a school counsellor accessible to children inside every school, every day.
The articles of the CRC align with the aims of the Governments of Canada and British Columbia as well. In 2006, the Senate of Canada recommended, “that mental health services for children and youth be provided in the school setting by the school-based mental health teams” (source). The Mental Health Strategy for Canada also states, “Priority 1.2: Increase the capacity of families, caregivers, schools, post-secondary institutions, and community organizations to promote the mental health of infants, children, and youth; prevent mental illness and suicide whereveer possible; and intervene early when problems first emerge (source). Finally, the BC Ministry of Mental Health and Addictions “A Pathway to Hope” clearly states that mental health in schools is a priority, focusing on prevention, promotion, early intervention, and “supports in schools through school counsellors” (source).
5.2 Here’s What We Can Do
Every citizen of British Columbia can advocate for guaranteed access to qualified mental healthcare for every child. If you wish to advocate, then please read on.
You can start by talking to family, friends, and colleagues. People deserve to be informed about the mental health care system, children’s mental health, and the other topics covered in this article. You can also share this article and your own thoughts or opinions over the internet and social media.
The next step is to reach out to your local Member of the Legislative Assembly (MLA) to ask for assistance. MLAs are representatives for the people who live in the region they represent. The concerns you voice to them affect the way BC functions. Every MLA has their contact information publicly listed on their profile on the Government of BC website. You can write e-mails or letters or even call the constituency office.
Some MLAs are also Ministers. Ministers have much power to influence the decisions that are made in BC, since they are also responsible for the operations of a Ministry. Here are the profiles for the current Ministers of Children and Family Development, Education, Health, and Mental Health & Addictions. Again, you can write e-mails or letters or even make a phone call.
5.3 Sample Letter to an MLA
You will find an example letter to an MLA below. It contains basic details about the state of mental healthcare in BC, the children’s mental health crisis, and proposed actions to guarantee access to mental healthcare for every child. You can use this letter as is or edit it to better suit your voice.
Dear _____,
Right now, many children in BC cannot access qualified mental health care. This is having a devastating effect on their well-being, their learning, and their families. If children in need go without treatment, it will also bankrupt our health care system, drain our workforce, and strain our economy in the years to come.
We need to expand and strengthen the services that serve children and their families: (1) School counsellors working in the school system and (2) Child & Youth Mental Health. As outlined in the Convention on the Rights of the Child, these services require an adequate number of suitably trained staff to ensure the safety and health of the children they serve. Presently, these services cannot keep up with the level of need because they are understaffed and underfunded.
Right now, more than ever, we need to guarantee access to mental health care for every child in BC. Before the pandemic, children’s mental health was already in crisis. Now, two years later, the pandemic has negatively affected children’s mental health worse than any other population.
Guaranteed access is a goal that requires political commitment and action. The following recommendations follow from research on children’s mental health, the aims of the Government of BC and the Government of Canada, and the inalienable rights of children outlined in the Convention on the Rights of the Child:
Ensure there is a school counsellor inside every school, every day
Create a province-wide standard for student to school counsellor ratios set at 250:1, upheld in every school district
Hire an adequate number of school counsellors to staff the schools
Ensure all school counsellors are suitably trained: they hold a valid BC Teacher’s Certificate and a Master’s degree in Counselling Psychology or a related subject
Remove policies which interfere with provision of counselling services
Enhance the capacity of Child & Youth Mental Health
Hire an adequate number of suitably trained staff to meet the current mental health needs of children in BC
Implement Integrated Child and Youth (ICY) teams in every region in BC
Establish and maintain linkages between all services for children (CYMH, ICY teams, schools, etc.)
Regulate counselling therapy in British Columbia
Yours sincerely,
_____
Afterword
I am a School Counsellor, and it is my responsibility to advocate for the needs of all students. My profession and identity bias my perspective and also offer a unique, frontline point-of-view for understanding children’s mental health. The claims in this article are supported by references to research, government publications, and current events. Nevertheless, please check them against your own experience.
This article follows one month after the Greater Victoria School District announced proposed budget changes for next school year. One of the proposed changes would reduce the number of school counsellors in the district by 8 full-time positions (source 1, source 2). This generated public discussions, and demonstrations. On 8 April, 2022, the new budget was approved with no reductions to school counsellors. Although no reductions were made, the fact that they were proposed at all is extremely concerning.
I remain hopeful that we can create a future where every child gets the care they need where they are and when they need it. My hope comes from meeting the incredible people who work in education and child mental health right now. They are passionate and excellent at what they do. During the Coronavirus Disease (COVID-19) Pandemic, they have shown incredible resilience and commitment to the responsibility of caring for children during unprecedented circumstances. I have also met the students currently training in these fields, and I feel confident that the next generation of professionals are already driven and courageous. We have the right people for the job right here, right now, and they want to serve children and families. The issue is not availability, it is access. We need to remove the barriers that prevent these professionals from being able to meet the needs of children.
All of us can care for and protect children’s mental health through advocacy.
Thank you for reading.
References
There are too many references to host on this site, so they are embedded into the article. If requested, I can provide a full list of citations.