All too often we see tragedies caused by young adults who did not receive the mental health care they needed during childhood. Each time such a tragedy occurs, it fleetingly brings the issue of mental health back to the national stage. Little has been done systemically, however, and the underlying challenges have not been fully addressed. The BRAIN initiative [a public-private partnership) promoted by President Obama is a positive step, as it seeks to develop a sophisticated understanding of the brain from studies of individual genes, neural circuitry and behavior. Yet, this is but one part of what must be a complex, ultimately personalized, solution [1].

Child mental health is undoubtedly a complex part of cognitive neuroscience, driven by different feedback processes underlying the genetic or environmental system. A recent study confers the relationship between familial inbreeding and modest cognitive impairments among children, providing the evidence for inbreeding depression on intellectual behaviors on comparing with environmental and socioeconomic variables [2].

Children’s mental health has been identified for too long as one of the most underserved areas in medicine-under-staffed, under-funded, poorly reimbursed and poorly understood from a research perspective [3]. When care is available, it is often delayed. Furthermore, diagnosis is inexact and therapies are frequently neither individualized nor evidence-based. Yet, mental illness is very much a “childhood” issue, as its symptoms appear by age 14 in half of lifetime cases of severe conditions [bipolar disorder, depression, and schizophrenia] [4,5]. Even less severe behavioral and mental health disorders, such as anxiety disorders, Obsessive Compulsive Disorder [OCD], and Attention Deficit Hyperactivity Disorder [ADHD] are detectable in childhood, and greatly affect a child’s overall health, development, learning abilities and future competitiveness in society.

Nationally, one in five children will have a diagnosable mental health disorder that is severe enough to impair functioning in the home, school or community; but only about 20 percent receive treatment [4,5]. More youth and young adults die from suicide than from all natural causes combined [38,364 per year in the U.S.]; and 90 percent of those who die by suicide have an identifiable mental health disorder. Approximately half of students under age 14 with mental illness drop out of school [4,5]. Seventy percent of youth in state and local juvenile justice systems have mental disabilities.

As the Milliman report of adults with mental health disorders highlights, integrated care is essential as it results not only in improved outcome but in measureable financial savings [6]. On a purely economic basis, early identification and effective treatment in childhood are cost effective and will result in decreased lifetime care costs and increased earning potential for the individual. In other pediatric chronic conditions-such as obesity, asthma and diabetes-early detection and intervention have produced a positive effect on patients’ health as they enter adulthood and have led to improved lifetime outcomes. For mental health issues as well, research has shown that early recognition and timely intervention can delay or prevent the onset of psychopathology and result in faster, more complete recovery. It can also decrease the frequency and severity of relapses. A 33-year follow-up study of children with ADHD demonstrated the value of early treatment. Children who did not receive intervention experienced an increased likelihood of incarceration and death in adulthood compared to matched controls [7] Findings highlight the importance of extended monitoring and treatment of children with ADHD [7]. In another study children with a high risk for psychosis who received early identification and treatment did not develop a psychotic disorder, demonstrating that the course of psychosis is not fixed as was previously believed [8].

Pediatricians have an important role to play in identifying and initiating treatment of mental health disorders, especially given the documented shortage of child and adolescent psychiatrists. Yet, many challenges remain to ensure that pediatricians have the skills, knowledge and time to properly identify and treat mental health concerns and to make appropriate referrals. [9,10] A collaborative “medical home” model is needed to address access to mental health care. The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the sub-specialty Boards of the American Board of Pediatrics [ABP] and the American Board of Psychiatry and Neurology [ABPN] are actively collaborating on deciding how best to educate and assess competence of pediatricians in diagnosing and treating mental health issues.

Moreover, a fundamental change in our approach to the diagnosis and treatment of childhood mental illness is needed. Mental illness does not generally arise solely from family stresses or environmental influences. There is evidence that discernible molecular aberrations in genetics, brain structure, function, cellular signaling and connectivity can place individuals at increased risk for mental illness from early childhood [11]. Only after these endogenous alterations are identified, through further research studies, can mental conditions be assessed and treated as medical conditions. They then can be approached and “cured” by personalized, precise treatments-rather than lumped into misleading categories, resulting in non-specific, often ineffective treatments.

These challenges were recognized in a June 2013 White House Mental Health Summit-the first in fifteen years focusing on pediatric psychiatric issues and in a subsequent national meeting convening government policy makers, National Institute of Mental Health leaders, and directors of psychiatry and pediatrics of major children’s hospitals. According to the President’s New Freedom Commission on Mental Health, “no other illness has damaged so many children so seriously.” Given these challenges and opportunities, the following initiatives are critically required.

Providing timely access to care-Recognizing the existing delays between the onset of symptoms and initiation of interventions, we must guarantee quicker access to treatment that is evidence-based. Time and resources invested in a child’s care at the onset of symptoms will result in a quantifiable improvement in future health, quality of life, and cost of care. This will require the training of more mental health professions devoted to the treatment of children.

Developing standards of care-The United States has many guidelines for mental health treatment and care but no standards of care. These must be established and enforced as part of the Affordable Care Act.

Removing the stigma of mental illness in children-Despite some progress, the stigma associated with the diagnosis of a mental health disorder is alive and well and prevents many youth and/or their parents from seeking care. Such barriers must be removed, and mental illness should be considered as a chronic medical condition and health care provided as such.

Performing clinical and translational research: Rapid advances in neuroscience and genetics open great clinical and translational research opportunities including the identification of molecular targets and pathways for innovative pharmacotherapeutics, as well as use of biomarkers that allow earlier detection and provide endpoints for intervention trials. Enhanced funding for this research is needed.

Fostering models of cross-disciplinary integration-We need to ensure cross-disciplinary mental health assessment for children, spanning pediatrics, psychology/psychiatry, social work, physical medicine and rehabilitation, neuropsychology and neurology. We must foster collaborations amongst specialists from neurology, psychiatry, genetics and behavioral disciplines, with seamless integration between clinical and academic spheres. The payment system needs to support such collaborative approach to care.

Increasing funding for mental health-Funding and enforcement of mental health parity with other medical illnesses is equally important. Without holding payers responsible for mental health care reimbursement, even the best evidence-based treatments will be inaccessible to much of the population.

We are now in the unique position of having potentially increased the resources, through the Affordable Care Act, and the scientific knowledge through research to start addressing these issues in a comprehensive way. The work across many disciplines of children's mental health care needs our sincere attention to spur progress on all of the fronts to effectuate the shortcomings in the current approach.