The Role of Infrastructure in the Transformation of Child–Adolescent Mental Health Systems

  • Wayne StelkEmail author
  • Elaine Slaton
Original Paper


There is a widespread recognition that the mental health system is not effective in meeting the needs of the children, adolescents, and families who seek its services. In response to this recognition, researchers and policy makers are developing and implementing strategies to transform mental health systems. This paper suggests that transformational interventions should not proceed faster than our understanding of the complexities of a mental health system. In a complex system, all component parts are interactive and interdependent. Problems with one component cannot be solved in isolation from other components. The inter-relationships between problems create inter-dependencies; and changes in the balance of these inter-dependencies can cause dramatic shifts in policy priorities, such as when managers of mental health systems respond to budget reductions in a recessionary economy. This paper examines the problem domains in mental health systems that are affected by complexity dynamics, and proposes that a well-built infrastructure is a necessary foundation for structural change in a child–adolescent mental health system. The concept of metastructure is proposed to account for the rule-based processes that govern the actions of agents within a system.


Mental health Child–adolescent Complexity Infrastructure Evidence-based practices Participatory decision-making Program evaluation Feedback systems 


  1. Abramson, J. S., & Mizrahi, T. (2003). Understanding collaboration between social workers and physicians: Application of a typology. Social Work in Health Care, 37(3), 71–100.CrossRefPubMedGoogle Scholar
  2. Ashby, W. R. (1962 (republished in 2004)). Principles of the self-organizing system. E:CO, 6(1–2), 102–126.Google Scholar
  3. Axelrod, R. (1997). The complexity of cooperation: Agent-based models of competition and collaboration. New York: Princeton University Press.Google Scholar
  4. Baker, T. B., McFall, R. M., & Shoham, V. (2009). Current status and future prospects of clinical psychology: Toward a scientifically principled approach to mental and behavioral health care. Psychological Science in the Public Interest, 9(2), 67–103.Google Scholar
  5. Banks, A. P., & Millward, L. J. (2000). Running shared mental models as a distributed cognitive process. British Journal of Psychology, 91, 513.CrossRefPubMedGoogle Scholar
  6. Barkley, R. A. (2004). Attention-deficit/hyperactivity disorder and self-regulation. In R. F. Baumeister & K. D. Vohs (Eds.), Handbook of self-regulation. New York: Guildford Press.Google Scholar
  7. Becvar, D. S. (2003). Eras of epistemology: A survey of family therapy thinking and theorizing. In T. L. Sexton, G. R. Weeks, & M. S. Robbins (Eds.), Handbook of family therapy: The science and practice of working with families and couples (Kindle Ed.). New York: Brunner-Routledge.Google Scholar
  8. Bickman, L. (2008). Why don’t we have effective mental health services? Administration and Policy in Mental Health and Mental Health Services Research, 35(6), 437–439.CrossRefPubMedGoogle Scholar
  9. Bjorklund, R. W., Monroe-DeVita, M., Reed, D., Toulon, A., & Morse, G. (2009). State mental health policy: Washington State’s initiative to disseminate and implement high-fidelity ACT teams. Psychiatric Services, 60(1), 24–27.CrossRefPubMedGoogle Scholar
  10. Bronfenbrenner, U. (Ed.). (2005). Making human beings human: Bioecological perspectives on human development. Thousand Oaks: Sage Publications.Google Scholar
  11. Camazine, S., Deneubourg, J.-L., Franks, N. R., Sneyd, J., Theraulaz, G., & Bonabeau, E. (2001). Self-organization in biological systems. Princeton: Princeton University Press.Google Scholar
  12. Carpinello, S. E., Rosenberg, L., Stone, J., Schwager, M., & Felton, C. J. (2002). Best practices: New York state’s campaign to implement evidence-based practices for people with serious mental disorders. Psychiatric Services, 53(2), 153–155.CrossRefPubMedGoogle Scholar
  13. Carver, C. S. (2004). Self-regulation of action and affect. In R. F. Baumeister & K. D. Vohs (Eds.), Handbook of self-regulation (pp. 13–39). New York: Guildford Press.Google Scholar
  14. Cashin, C., Scheffler, R., Felton, M., Adams, N., & Miller, L. (2008). Transformation of the California mental health system: Stakeholder-driven planning as a transformational activity. Psychiatric Services, 59(10), 1107–1114.CrossRefPubMedGoogle Scholar
  15. Cavaleri, M., Gopalan, G., McKay, M. M., Apel, A., Bannon, W. M., & Bigley, M. F. (2006). Impact of a learning collaborative to improve mental health service use among low-income, Urban youth and families. Best Practices in Mental Health: An International Journal, 2(2), 67–79.Google Scholar
  16. Crump, D. (2007). Developing a prevention-oriented mental health system in Washington State. Olympia: Washington State Board of Health.Google Scholar
  17. Davis, M., Geller, J. L., & Hunt, B. (2006). Within-state availability of transition-to-adulthood services for youths with serious mental health conditions. Psychiatric Services, 57(11), 1594–1599.CrossRefPubMedGoogle Scholar
  18. Dooley, K. J. (2004). Complexity science models of organizational change and innovation. In M. S. Poole & A. H. Van de Ven (Eds.), Handbook of organizational change and innovation (pp. 354–373). New York: Oxford University Press.Google Scholar
  19. Edwards, B. C., & Smith, V. K. (2007). State mental health policy: Insights and opportunities: Medicaid directors identify mental health issues. Psychiatric Services, 58(8), 1032–1034.CrossRefPubMedGoogle Scholar
  20. Espevik, R., Johnsen, B. H., Eid, J., & Thayer, J. F. (2006). Shared mental models and operational effectiveness: Effects on performance and team processes in submarine attack teams. Military Psychology, 18, 23–36.CrossRefGoogle Scholar
  21. Ferlie, E. B., & Shortell, S. M. (2001). Improving the quality of health care in the United Kindgdom and the United States: A framework for change. The Milbank Quarterly, 79(2), 281–315.CrossRefPubMedGoogle Scholar
  22. Ferlie, E., Fitzgerald, L., Wood, M., & Hawkins, C. (2005). The nonspread of innovations: The mediating role of professionals. Academy of Management Journal, 48(1), 117–134.CrossRefGoogle Scholar
  23. Fernandez-Berrocal, P., & Santamaria, C. (2006). Mental models in social interaction. Journal of Experimental Education, 74, 229–248.CrossRefGoogle Scholar
  24. Finnerty, M., Rapp, C. A., Lynde, D., & Goldman, H. H. (2005). State health authority yardstick (SHAY): Examining the impact of state MH authority action on quality and penetration of EBPs in commnity mental health centers. In Paper presented at the fifteenth annual conference on state mental health agency services research, program evaluation and policy, Baltimore, MD.Google Scholar
  25. Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network.Google Scholar
  26. Forrester, J. W. (1991). System dynamics and the lessons of 35 years.Unpublished manuscript.Google Scholar
  27. Frank, R. G., & Glied, S. A. (2006). Better but not well: Mental health policy in the United States since 1950. Baltimore: Johns Hopkins University Press.Google Scholar
  28. Ganju, V. (2008). State mental health policy: Mental health transformation: Moving toward a public health, early-intervention approach in Texas. Psychiatric Services, 59(1), 17–20.CrossRefPubMedGoogle Scholar
  29. Garfield, R. L. (2009). Mental health policy development in the states: The piecemeal nature of transformational change. Psychiatric Services, 60(10), 1329–1335.CrossRefPubMedGoogle Scholar
  30. Gilbert, N., & Troitzsch, K. G. (2005). Simulation for the social scientist (2nd ed.). Berkshire: Open University Press.Google Scholar
  31. Goldstein, J. (2008). Complexity science aplied to innovation—Theory meets praxis. The Innovation Journal: The Public Sector Innovation Journal, 13(3), 1–16.Google Scholar
  32. Greenhalgh, T., Roberts, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovation in service organizations: Systematic review and recommendations. The Milbank Quarterly, 82(4), 581–629.CrossRefPubMedGoogle Scholar
  33. Grimshaw, J. M., & Eccles, M. P. (2004). Is evidence-based implementation of evidence-based care possible? Medical Journal of Australia, 180, S50–S51.PubMedGoogle Scholar
  34. Hannon, B., & Ruth, M. (2001). Dynamic modeling (2nd ed.). New York: Springer.Google Scholar
  35. Hargrove, J. L. (1998). Dynamic modeling in the health sciences. New York: Springer.Google Scholar
  36. Hayes, A. M., & Strauss, J. L. (1998). Dynamic systems theory as a paradigm for the study of change in psychotherapy: An application to cognitive therapy for depression. Journal of Consulting and Clinical Psychology, 66(6), 939–947.CrossRefPubMedGoogle Scholar
  37. Helbing, D., Yu, W., & Rauhut, H. (2009). Self-organization and emergence in social systems: Modeling the coevolution of social environments and cooperative behavior (No. 09-07-026). Santa Fe: Santa Fe Institute.Google Scholar
  38. Held, C., Knauff, M., & Vosgerau, G. (Eds.). (2006). Mental models and the mind: Current developments in cognitive psychology, neuroscience, and philosophy of the mind. Heidelberg: Elsevier.Google Scholar
  39. Herzog, S. M., & Hertwig, R. (2009). The wisdom of many in one mind: Improving individual judgments with dialectical bootstrapping. Psychological Science, 20(2), 231–237.CrossRefPubMedGoogle Scholar
  40. Hoagwood, K. (2003). The policy context for child and adolescent mental health services: Implications for systems reform and basic science development. Annals of the New York Academy of Sciences, 1008(Roots of Mental Illness in Children), 140–148.Google Scholar
  41. Hogan, M. (2003). The president’s new freedom commission on mental health (No. Executive Order 13263), Washington, DC.Google Scholar
  42. Holland, J. H. (1995). Hidden order: How adaptation builds complexity. New York: Helix Books.Google Scholar
  43. Horwath, J., & Morrison, T. (2007). Collaboration, integration and change in children’s services: Critical issues and key ingredients. Child Abuse and Neglect, 31(1), 55–69.CrossRefPubMedGoogle Scholar
  44. Hyde, P. S. (2004). State mental health policy: A unique approach to designing a comprehensive behavioral health system in New Mexico. Psychiatric Services, 55(9), 983–985.CrossRefPubMedGoogle Scholar
  45. Isett, K. R., Burnam, M. A., Coleman-Beattie, B., Hyde, P. S., Morrissey, J. P., Magnabosco, J., et al. (2007). The state policy context of implementation issues for evidence-based practices in mental health. Psychiatric Services, 58(7), 914–921.CrossRefPubMedGoogle Scholar
  46. Kauffman, S. A. (1995). At home in the universe: The search for the laws of self-organization and complexity. New York: Oxford University Press.Google Scholar
  47. Kerr, N. L., & Tindale, R. S. (2004). Group performance and decision making. Annual Review of Psychology, 55, 623–655.CrossRefPubMedGoogle Scholar
  48. Loh, M., Rolls, E. T., & Deco, G. (2007a). A dynamical systems hypothesis of schizophrenia. PLoS Computational Biology, 3(11), 2225–2235.CrossRefGoogle Scholar
  49. Loh, M., Rolls, E., & Deco, G. (2007b). The symptoms of schizophrenia related to the stability of attractor networks. BMC Neuroscience, 8(Suppl 2), P142.Google Scholar
  50. Mazade, N. A., & Glover, R. W. (2007). State mental health policy: Critical priorities confronting state mental health agencies. Psychiatric Services, 58(9), 1148–1150.CrossRefPubMedGoogle Scholar
  51. Miller, J. H., & Page, S. E. (2007). Complex adaptive systems: An introduction to computational models of social life. Princeton: Princeton University Press.Google Scholar
  52. Plsek, P. E. (2003). Complexity and the adoption of innovation in health care. In Paper presented at the conference on accelerating quality improvement in health care: strategies to speed the diffusion of evidence-based innovations, Washington, DC.Google Scholar
  53. Plsek, P. E., & Greenhalgh, T. (2001). The challenge of complexity in health care. BMJ, 323(7313), 625–628.CrossRefPubMedGoogle Scholar
  54. Power, A. K. (2009). Focus on transformation: A public health model of mental health for the 21st century. Psychiatric Services, 60(5), 580–584.CrossRefPubMedGoogle Scholar
  55. Prochaska, J. O., & Norcross, J. C. (1999). Systems of psychotherapy: A transtheoretical approach (4th ed.). Pacific Grove: Brooks/Cole Publishing Co.Google Scholar
  56. Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in mental health services: an emerging science with conceptual, methodological, and training challenges. Administration and Policy in Mental Health and Mental Health Services Research, 36(1), 24–34.CrossRefPubMedGoogle Scholar
  57. Sawyer, R. K. (2005). Social emergence: Societies as complex systems. New York: Cambridge University Press.Google Scholar
  58. Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. New Jersey: Lawrence Erlbaum Associates.Google Scholar
  59. Schwab, J. J., Gray-Ice, H. M., & Prentice, F. R. (2000). Family functioning: The general living systems research model (Kindle Ed.). New York: Kluwer Academic.Google Scholar
  60. Sederer, L. I. (2008). Mental health policy and services five years after the president’s commission report: An interview with Michael F. Hogan. Psychiatric Services, 59(11), 1242–1244.CrossRefGoogle Scholar
  61. Siegel, C., Haugland, G., & Chambers, E. D. (2004). Cultural competency assessment scale with instructions: Outpatient service delivery agency level. Unpublished Manuscript, Nathan S. Kline Institute of Psychiatric Research.Google Scholar
  62. Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: The Guildford Press.Google Scholar
  63. Sterman, J. D. (2006). Learning from evidence in a complex world. American Journal of Public Health, 96(3), 505–514.CrossRefPubMedGoogle Scholar
  64. Supekar, K., Musen, M., & Menon, V. (2009). Development of large-scale functional brain networks in children. PLoS Biol, 7(7), e1000157.CrossRefPubMedGoogle Scholar
  65. Sutton, R. S., & Barto, A. G. (1998). Reinforcement learning: An introduction. Cambridge: The MIT Press.Google Scholar
  66. The State of Health Care Quality. (2009). Washington, DC: National Committee For Quality Assurance.Google Scholar
  67. Thelen, E., & Smith, L. B. (1994). A dynamic systems approach to the development of cognition and action. Cambridge: The MIT Press.Google Scholar
  68. Unutzer, J., Schoenbaum, M., Druss, B. G., & Katon, W. J. (2006). Transforming mental health care at the interface with general medicine: Report for the presidents commission. Psychiatric Services, 57(1), 37–47.CrossRefPubMedGoogle Scholar
  69. Whitley, R., Gingerich, S., Lutz, W. J., & Mueser, K. T. (2009). Implementing the illness management and recovery program in community mental health settings: Facilitators and barriers. Psychiatric Services, 60(2), 202–209.CrossRefPubMedGoogle Scholar
  70. Willging, C. E., Tremaine, L., Hough, R. L., Reichman, J. S., Adelsheim, S., Meador, K., et al. (2007). State mental health policy: “We never used to do things this way”: Behavioral health care reform in New Mexico. Psychiatric Services, 58(12), 1529–1531.CrossRefPubMedGoogle Scholar
  71. Wu, P., Katic, B. J., Liu, X., Fan, B., & Fuller, C. J. (2010). Mental health service use among suicidal adolescents: Findings from a US national community survey. Psychiatric Services, 61(1), 17–24.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Innovation Management Resources, LLCMarbleheadUSA
  2. 2.Training and EvaluationNational Federation of Families and Children’s Mental HealthRockvilleUSA
  3. 3.MarbleheadUSA

Personalised recommendations