At best, the contributors to this issue generally argue, the benefits of the child mental health system, as it conventionally operates, are undocumented. Perhaps more likely, the benefits typically are modest or even nil. At worst, the harms known or reasonably believed often to be associated with child mental health services may exceed the benefits.Footnote 1

The question that reasonably flows from these stark conclusions and that this special issue addresses is, “How can the child mental health system be reformed in ‘real life’ [usual practice] so that it matches common sense and empirical research?” The contributors to this issue generally address this core question thoughtfully and creatively but with a certain level of exasperation. The implicit assumption appears to be that the critical needs in child mental health policy and practice are for greater interest in, and responsiveness to, research (both actual and potential) on the system’s effectiveness and efficiency. Hence, the remedies that the contributors propose typically relate to mechanisms for documentation of services delivered, evaluation of their outcomes, diffusion of knowledge, preparation of the workforce, persuasion of policymakers and practitioners, tools for decision making (e.g., expert systems), and ongoing feedback to providers.

In that regard, I reiterate (see Melton 1997; Melton and Lyons 2010) the importance of the question of the nature and causes of the irrationality in much—probably most—of the child mental health system, including the organizations that are outside specialty mental health agencies but that have express or implicit purposes of behavior change in children who are troubled or (more often) troubling and their families. (Given the common failure to regard these organizations as part of a single system, history indicates that the “natural” consequence of reform in the child mental health system—or in juvenile justice, child welfare, special education, or perhaps primary health care—is simply to move young people and their families from one agency to another; see Melton et al. 1998, chap. 1.) I also acknowledge that the continuing difficulty in even describing—much less changing—the operation of the youth-in-trouble system (cf. Lerman 1980) is often maddeningly frustrating. It is clear that the ruts run deep on the paths most traveled (the paths of least resistance to the status quo) in the child mental health system, even though they often misdirect clinicians and policymakers and, therefore, the children and families whom they strive to serve.

No one may reasonably argue that pervasive irrationality in the operation of the system is inconsequential. In both the near term and the long term, mental health problems may have horrendous effects on children themselves, their families, and their communities. Moreover, the importance of care in the operation of the child mental health system is magnified by the acutely sensitive domains of life that mental health services touch.

Nonetheless, in my judgment, the contributors to this issue have not looked far enough in identifying the core issues in the child mental health system. Their vision has not extended to the proverbial elephants in the room: (a) the stunning and long-increasing prevalence of child mental health problems in the United States (and probably elsewhere, at least in the industrialized world; see Pharr and Putnam 2000) and (b) the even more stunning and also long-increasing difficulty in providing parents and other caregivers with the support needed to promote children’s mental health and to prevent and ameliorate their mental health problems.Footnote 2 Although some of the bureaucratic and scientific issues discussed in this issue seem virtually intractable, their significance pales in comparison to the magnitude and potency of the two trends that I have raised. In the face of these powerful social forces, merely tweaking the mechanisms of quality improvement and assurance (even if doing so is a formidable, often unfulfilled task) will not take the child mental health system beyond a point of marginal social relevance.

There is startling and mounting evidence of dramatic and continuing generational increases in anxiety, depression, and psychopathic deviation among children, adolescents, and young adults, to the point that “clinical” dysfunction in prior generations is now average (see, e.g., Irvine 2010; Munsey 2010; Seligman 1995; Twenge 2000, 2006; Twenge and Campbell 2009). These experiences of sadness and fear are complemented, unfortunately, by even more pronounced growth in experiences of boredom, alienation, and a general sense of a lack of personal control, even among young people who “make it” and achieve at high levels (see, e.g., Astin et al. 2002; Larson 2000). The evidence is also clear that these trends are closely and probably causally related to declines in the strength and depth of relationships across the society, as trust of institutions and, even more disturbingly, one’s neighborsFootnote 3 continues to plummet, especially among young people (see, e.g., Pharr and Putnam 2000; Putnam 2000; Twenge 2000).

Mental health professionals and organizations should be joining diligently and energetically with other sectors of society (not just professional helping services) to strengthen informal connections among people and to facilitate neighbors’ help for one another. This approach is sensible for both prevention and treatment (see Melton 2010, for detailed discussion of this point). Immediacy and “naturalness” of help are important elements of both short- and long-term effectiveness of treatment even for relatively intractable and pervasive disorders of childhood (see, e.g., Henggeler et al. 2009). Similarly, for broad-based prevention of behavioral and emotional problems and for promotion of mental health, universal approaches embedded in the institutions of everyday life are logically required (National Research Council & Institute of Medicine [NRC/IoM] 2009). In both instances, acceptability of an intervention is highly related to its naturalness (Melton and Lyons 2010); no one wants help to be conditional on being patients, clients, or, worst, cases. In effect, to use the slogan of the institute in which I work, “people shouldn’t have to ask!”

There are multiple examples of effective use of population approaches to prevention (NRC/IoM, 2009). My own recent work takes the premise a step further by mobilizing entire communities to change the norms of family support. In Strong Communities for Children (Melton 2009; Melton and Holaday 2008), my colleagues and I mobilized a multi-county area of about 125,000 people to work toward creation of communities in which all parents and children knew that if they had reason to celebrate, worry, or grieve, someone would notice, someone would care.

Aimed ultimately at “keeping kids safe,” the initiative engaged hundreds of organizations and thousands of volunteers. Relying on just one outreach worker per town, this achievement was itself major, in that it signaled a change in the quality of life for families and the efficacy of parents and volunteers. The measured effects were even more impressive, however (Melton 2009; Melton et al. 2010). Across a 3-year period and in comparison with matched communities, randomly selected parents in the participating communities reported greater social support, more frequent help from others, greater sense of community and personal efficacy, more frequent positive parental behavior, more frequent use of household safety devices, less frequent disengaged (inattentive) parental behavior, and less frequent child neglect.

These self-reports in a community survey were corroborated in surveys of parents, teachers, and children themselves in elementary schools reported greater sense of safety at and on the way to school (across time and relative to matched schools). The schools were also perceived to be increasingly open to parents. Moreover, the rate of maltreatment, especially neglect, substantiated by Child Protective Services dropped among children under age 10, again in relation both to time and matched communities. Similar changes among children under age 6 were observed in hospital admission data.

In short, formidable negative social trends are present in child mental health and social support for parents and for children themselves. Concern about these trends should be at the forefront of mental health policy. The resulting interventions should not only go beyond traditional psychotherapy; they should go beyond “out-stationing” of clinicians in formal programs in schools and other community settings. It is time to mobilize the expertise of mental health practitioners and the efforts of mental health researchers to become true agents of social change, to make communities safe and humane (“mentally healthy”) environments for all children and families, no matter what their level of distress.