Two-fers in Mental Health Services

The concept of a “two-fer” dates to the late 19th century when two (usually cheap) cigars would be sold for the price of one. This sales gimmick generalized and is now a staple of cable TV marketing, often introduced by an excited, “But wait! There’s more. Get a second whizamadoodle. Just pay extra shipping and handling. That’s two whizamadoodles for the price of one. A real bargain!”

For clinicians and policy wonks, however, a real public health bargain is what one might call a therapeutic two-fer, an intervention that simultaneously targets two co-occurring problematic symptoms, such as depression and anxiety. One of the greatest public health bargains of all is a clinical intervention for one generation that positively affects another generation as well. Most commonly this intergenerational two-fer is observed between parents and their children.

The Great Smoky Mountains Study

One of the first research studies to systematically examine the intergenerational two-fer effect of an increase in a family’s base income and better outcomes for their children was the Great Smoky Mountains Study (GSMS).¹ Begun in 1992, by E. Jane Costello, William Copeland, and Adrian Angold of Duke University, the GSMS investigated children’s mental health needs in rural America. Serendipitously in 1996, a casino opened on a Cherokee reservation located in the study area. A proportion of the casino profits (~$4000) was distributed equally to every enrolled member of the tribe (children’s shares were held by the Tribal Council until graduation from high school or age 21). Anglo-American families in surrounding counties did not receive any additional income. The GSMS compared the average number of DSM-IV emotional and behavioral symptoms in Anglo and Native American children for the 4 years before and 4 years after the casino opened. Native American families receiving this income supplement showed marked improvements in their children’s mental and behavioral health with no changes in the Anglo children.

More recently, a similar study examining the long-term, intergenerational effects of a large cash transfer to Native American families found that beneficial effects were measurable in their children and even their grandchildren many years later.² Specifically, their children had healthier pregnancies as adults and their children’s children (i.e., the grandchildren of the original cash recipients) were healthier at birth compared with equivalent Anglo families that did not receive the cash transfer. This suggests that such interventions may even have “three-fer” intergenerational effects.

Another Three-Fer

A study published this year followed up on a parent, child, and school-based intervention carried out at low-income schools in four states for children who showed signs of aggression in first grade. When these children became parents, those who had received the intervention were less likely to use corporal punishment, and their children were significantly less likely to use general medical inpatient services or either inpatient or outpatient mental health services. The authors conclude that “Investing in interventions for the mental health of children could reduce service use burdens across generations.”³

Child PTSD Prevention Program Reduces Parental PTSD Symptoms

Studies and meta-analyses have consistently found that posttraumatic stress disorder (PTSD) symptoms in parents adversely affect their offspring. Likewise, PTSD symptoms in children affect their parents. (This is likely also true for major depression and generalized anxiety disorder). Correspondingly, there are examples where therapeutic interventions that address PTSD symptoms in one generation reduce PTSD symptoms in another.

For example, a multi-site (10), meta-analysis of PTSD symptoms in parents whose children received the Child and Family Traumatic Stress Intervention, a brief, manualized mental health intervention that significantly decreases the likelihood of acutely traumatized children developing full-fledged PTSD, also significantly reduced PTSD symptoms in their parents.⁴ In fact, virtually all of the most efficacious child trauma treatment programs involve the parents—although to different degrees.

It should be noted, however, that small percentages (3 percent in the above study) of parents are more symptomatic following participation in child-focused trauma interventions. There doesn’t seem to be a single explanation for this negative effect. But it speaks to the complicated, reciprocal interactions existing between parents and their children.

The Expanded Child Tax Credit

Perhaps the most powerful psychosocial two-fer on the horizon is the potential reinstatement of the Expanded Child Tax Credit (ECTC), which has not been determined as of this draft. Following the tragically short-lived, original ECTC, an analysis compared 2021 rates of child abuse (i.e., emergency room visits coded as child abuse-related) with the same periods in 2018 and 2019. There were significant reductions in child maltreatment for males and non-Hispanic white children following distribution of the original ECTC payments.⁵ These reductions in child maltreatment reports were limited, however, to relatively short time periods following a family’s receipt of an ECTC payment. Other research hints at longer-lived positive outcomes, but as with the birth and third-generation outcomes for family income transfers, we need much longer-term follow-up studies to document such benefits.

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From a public health perspective, the sad fact is that there is no greater bargain than early interventions to support caregivers and children, but it often takes years to see the payoff, while the politicians who make the ultimate decisions about funding such services primarily think in terms of the next election cycle.