President’s Corner - John L. Santa, Ph.D.
July 2006

Recent news articles have caught my attention by highlighting several alarming trends. Education Week recently reported that the national high school drop out rate is over 30%, with many states and urban areas exceeding 50% drop out rates. The total drop outs each year amount to more than 1.2 million students failing to graduate with their peers. An article in the New York Times (June 15, 2006) was titled “The DNA Age: That Wild Streak? Maybe it runs in the Family” suggesting that risk taking behavior at least in mice might be linked to a particular gene. And the Journal of the American Academy of Pediatrics recently published a summary of the rising prevalence of antidepressants among US youths (Zito, et al., Vol 109,5, May 2002, pp721-727) stating that the use of antidepressants for youth in the United States has risen by more than 350% from 1988 to 1994. More recent summaries suggest the use of antidepressants has continued to increase similarly in the past decade. In fact, an article in Psychiatric Times reports that in 2005 psychiatrists included in their top ten prescriptions more than 17 billion doses of antidepressants, 8 billion doses of anti-psychotics, 2 billion mood stabilizers, and more than 8 billion stimulants in a single year. These are astounding numbers, and one can only imagine how large they might be if the count were expanded to include all psychotropic prescriptions by family practitioners and all other specialties.

So, why have these assorted headlines caught my attention and how are they at all relevant to NATSAP member programs? First, the drop-out rate suggests a major failure in our culture to contain adolescents and create necessary identification with adult societal values. I believe this lack of cultural containment will lead to a vast increase in demand for NATSAP programs since most of our programs reconnect adolescents with basic values and responsibilities Second, the emphasis on genetic explanations and psychotropic treatment reflects an increasing trend to the use of a medical/biological level of diagnosis and treatment. The biological focus often ignores psycho-social treatments in an effort to make sense of adolescent struggles at the level of the synapse.

Pharmaceutical companies, government agencies, insurance companies and managed care organizations all have considerable economic interest in containing treatment costs, limiting access to service, and addressing treatment entirely within the medical model. As they market diagnosis by symptom cluster and manualized short term treatments coupled with medications aimed at cost containment and symptom abatement, pressure will mount to justify our out of home, longer term placements as effective “evidenced based” interventions.

Over the past fifteen years I have seen first hand the effectiveness of psycho-social milieu based, non-pharmaceutical intervention. Our impacts are not simply on immediate reduction in symptoms, although contained and nurturing environments do tend to provide remarkably fast symptom amelioration. Rather, our programs create contexts for true maturation and healthy character development in adolescents.

In this next period of time NATSAP as an organization, and programs both collectively and individually must come together to see how we can document our true impact. We urgently need relevant research aimed at creating appropriate diagnoses and measures of effectiveness. We cannot rely exclusively on measures of symptom abatement, or standardized indices of achievement and behavior. We must ask what we aim to change, what are the true agents of change in our programs, and how transportable are our effects. If we think the most important changes involve character development, morality, empathy, relationship success and engagement in the tasks of adult life, then we must define these qualities, and propose ways of measuring our effect.

What I am suggesting is that we as a profession must define our own measures of success and effectiveness. If we derive our own legitimate measures and are able to demonstrate effectiveness, as I am confident we can, then we have a chance of succeeding and protecting the creative psycho-social approaches we have all developed. If we wait passively to be measured by the standards imposed by governmental agencies, or compared to drug treatment and manualized treatments in terms of effect on their measures, we will fail and be absorbed into a standardized managed care world.