374 Chapter 43
mental health services for every million children and adolescents in the
general population. In Britain, the per capita spending on mental health
is over five times greater for adults than children. It is true that some of
the money spent by schools and social services is directed at the mental
health of children and adolescents – but not enough to make up for a
five-fold difference in mental health spending. It is not as if child and
adolescent mental health problems are rare. As pointed out in Chapter
3 and elsewhere, these problems are very common and have a large
immediate and delayed impact. In the short term, the problems distress
the affected individual and may also place considerable stress on parents,
siblings, teachers and classmates. In the longer term, failure to prevent or
treat child and adolescent mental health problems leads to more crime,
substance abuse, adult psychiatric disorder, school failure, unemployment
and poor parenting. Rather than neglecting tomorrow’s adults, there is a
case for investing early in their present and future mental health.
At the same time, though, it is important to remember that increased
mental health spending does not, by itself, guarantee improved mental
health. Buying more of the wrong thing will not help. This is the main
message of the Fort Bragg project, which cost $80 million and took five
years to carry out. The evaluation compared ordinary child and adolescent
mental health care with a more generously funded version that provided
a better integrated and more accessible service, and where clinicians were
effectively allowed to do what they thought best without having to worry
about costs. The cost per case roughly doubled, and families were more
satisfied, but there was no appreciable change in outcome, with children
and adolescents getting better at the same rate regardless. The research
team concluded that it had been a mistake to focus on the financing and
organisation of services without first ensuring that the services were deliv-
ering effective treatments. More of what you don’t need won’t necessarily
make you better.
High quality provision
The two mainstays of quality services are accurate assessment and
evidence-based treatment. These key topics are covered in almost every
chapter of this book. There is little to add here, other than noting that
while there is growing evidence about which treatments work best, some
CAMHS have been slow to adopt these. When there are proven treatments
available, it makes no sense to neglect these in favour of treatments that
have been shown to be largely or entirely ineffective, or treatments that
have not been properly evaluated. It is not only wasteful but also unethical
to deprive children and adolescents of effective treatments. Doing so
results in unnecessary suffering in the short term and may cause lasting
damage in the long term. Mechanisms need to be put in place to reward
services for employing effective treatments and discourage services from
continuing to use ineffective ones.