Redressing the Emperor: Improving Our Children's Public Mental Health System
John S. Lyons is a familiar figure to those involved in the movement to reform children's mental health systems. I approached this book with enthusiasm, eager to see what a senior figure in this movement had to say. I was not disappointed.
Lyons tells the history of children's public mental health services in a way that is more complete and better researched than most such reviews. He places it all on a time line filled with pearls that would be useful when giving talks on the subject. Recent familiar history is placed within this rich context. He then gives an excellent analysis of the problems in the children's health system by defining a series of tensions and whimsically named "syndromes" at various levels of an organization. Each touches on an important reality of children's services, and he handles the subject with the dispassionate eye of a scientist.
Lyons goes on to propose a vision of how to manage the tensions, emphasizing a commitment to prevention and service system management strategies. In this chapter he touches on the concepts of the youth's and the family's voice in the system of care. With this analysis he builds a foundation for his concept of total clinical outcome management. He devotes a chapter to an expansion of the variables that impinge on children's mental health by discussing many social factors that are critical to building healthy communities and then proposes innovative strategies for mobilizing communities to create jobs and take charge of social institutions, allowing all parents and youths to feel ownership in their communities. He presents his vision of total clinical outcome measurement with an erudite discussion of the dilemmas of program evaluation and proposes models of measurement that are comprehensive, standardized, and manageable. In this section he promotes his Child and Adolescent Needs and Strengths instrument for children and youths with mental health challenges (CANS-MH), the manual for which is included in the appendix. Finally he looks at the implications of applying total clinical outcome measurement to existing elements of the service system and to an evolving system of care. In this last section he touches on the role of families in systems of care generally as well as in the specific process of outcome management.
There is no doubt that Dr. Lyons has made a stunningly important contribution to the concept of system management and outcome measurement in children's mental health. His ideas will be recognized as sensible and thought provoking by all involved in that system. However, those who are deeply engaged in system reform may find some aspects of this book disappointing. Lyons appears timid in envisioning an expanded role for families and older youths in managing both individual care and becoming power-sharing players in management and program evaluation. He seems to be familiar neither with successes in the evolution of the family's and the youth's voice in many systems around the country nor with the potential for mobilizing nonprofessional community resources. Yet system reformers can forgive him these concerns, because he has contributed an essentially family- and youth-friendly model for the management and growth of mental health systems.
Dr. Huffine is assistant medical director for child and adolescent services in the chemical abuse and dependency services division of King County (Washington) Mental Health and has a private practice in child and adolescent psychiatry in Seattle.
