Can Frames Make Change? Using Communications Science to Translate the Science of Child Mental Health

Mental illness in children is on the rise in the United States, but research shows that the American public does not understand the science of child mental health—what it is and what supports and disrupts it. To build public understanding of child mental health and support for the systemic solutions needed to promote it, the FrameWorks Institute developed a “core story”—a master narrative—that advocates and experts in the field can use to communicate about the issue more effectively. This research is built on interviews with experts and members of the public, cognitive analyses of frames commonly used in media stories about the issue, and surveys of frame elements such as values and metaphors. Findings show that two values—Prosperity and Ingenuity—lifted support for policies related to child mental health. The Levelness Explanatory Metaphor, which compares child mental health to the levelness of a table, is also effective.


Introduction
Mental illness, long considered a taboo subject, is breaking into the public discourse. Lawmakers across the U.S. political spectrum, members of the American news media, and leading advocates and philanthropists in the country are increasingly paying attention to mental health issues. New laws have expanded access to mental healthcare services, and advocates are working to fulfill growing demands for treatments for a range of mental health disorders. As President Obama stated in 2016: "Mental health should be treated as part of a person's overall health, and we must ensure individuals living with mental health conditions can get the treatment they need." Nevertheless, advocates, experts, and practitioners still face significant obstacles in the way the public thinks about mental health-and particularly child mental health. We must overcome these barriers, and the cultural understandings that undergird them, if we hope to build public support for the services and supports that children and families need to promote good mental health and if we want our society to flourish in the future.
To do this, we must find new ways of talking with the public and policymakers about the science of child mental health. Mental illness in children, including conditions often diagnosed in childhood such as attention-deficit/hyperactivity disorder, behavioral disorders, and autism spectrum disorder, are on the rise [1]. And many children do not get the treatment they need when they need it. The average time between the onset of mental illness symptoms and intervention is 8-10 years, according to the National Alliance on Mental Illness (NAMI). Children with mental illness have lower educational achievement and greater involvement with the criminal justice system [2]-negative outcomes that affect individuals, families, and communities. Data clearly show that the inability of our systems to support positive child mental health is affecting our entire society.
To be sure, the national conversation does occasionally turn to child mental health, particularly in response to high-profile incidents in the news-when, say, an adolescent opens fire on his classroom peers. But these conversations do not advance the movement for better prevention strategies and much better treatment for children with mental illness. In fact, they reinforce the very patterns of public thinking that keep people from engaging productively with this issue. Part of the inability to move child mental health issues forward is due to an inhospitable communications environment-a cultural context in which messages about the science of child mental health and the importance of the systems that support it are unable to thrive and spread.
Child development scientists have made significant advances in recent decades, and the public does have more access to information about child mental health than previous generations did [3]. Yet our research, discussed below, shows that Americans do not understand the complex science behind mental health, particularly as it applies to children. They are not even sure child mental health exists-that children, and especially young ones, can in fact have "good" or "poor" mental health. Child development experts say that child mental health is a real phenomenon that requires public attention. But the public does not share this conviction; they do not appreciate the importance of this issue or the need for policies and systemic solutions.
Even when people are able to understand that children experience states of mental health, our research shows that they tend to equate good mental health with a narrow understanding of emotions and see solutions in individualistic terms rather than at the level of biology, development, or social context. According to this way of thinking, children can achieve good mental health if they have the discipline to control their emotions. Mental illness, on the other hand, is perceived as a genetic problem that has no cure but that can be managed to some degree by taking drugs to correct "chemical" imbalances. This way of thinking, as we discuss below, interferes with public support for potential solutions.
This lack of understanding undermines efforts to educate the public about child mental health and build public support for programs and policies that can support positive mental health and address mental health issues. When people have a better understanding of what child mental health is and when they can see what disrupts and promotes it, they are more likely to take steps to support policies and programs that promote good mental health in children and that increase access to high-quality treatment. Public support for child mental health policies, in other words, is not a matter of opinion but of cognition and understanding [4].
This chapter explores research conducted by the FrameWorks Institute, a communications think tank in Washington, D.C., to describe the "cognitive terrain" of thinking about child mental health in the United States and to provide advocates and experts with communications tools they can use to more effectively move through this terrain. It first "charts the landscape" by describing the differences between how child development experts and the American public understand child mental health and illness and then analyzes child mental health frames in use by the news media. Next, this chapter "redraws the map" by exploring the effect of communications tools and framing strategies on public understanding of the issue.

Charting the landscape
The Expert Story. In 2009, FrameWorks conducted extensive research on expert views of child and family mental health; public views of these issues; and of media frames. This work was undertaken in partnership with and with support from the Center on the Developing Child at Harvard University and was supplemented by initial funding from the Endowment for Health in New Hampshire. It builds on more than a decade of FrameWorks research on ways that frames-the strategic presentation of information that cues predictable responses-can build public understanding of the science of early brain and biological development. It is an important chapter in the "core story"-or master narrative-FrameWorks developed to more effectively communicate the science of early childhood.
FrameWorks undertook a two-step research process to understand the differences between how child mental health is understood by child development experts and by members of the U.S. public. First, researchers interviewed a panel of seven child development experts to distill the state of the science and refine the messages experts need to communicate with the public. This series of one-on-one hour-long interviews was supplemented by a review of relevant scholarly literature. Researchers found that-contrary to public narratives about the issueexperts emphasize that child mental health is a "real phenomenon" that has long-term implications for lifelong health and well-being [5]. They emphasized that child mental health is caused by interactions between a child's genes and the environment in which he or she lives and affects the child's ability to function in developmentally appropriate ways within the family and community. Experts often defined child mental health in negative terms-as the absence of symptoms or pathology-rather than in clear, positive ones. The science was clear, however, about the importance of early intervention and the fact that it can help prevent longterm effects for children who have symptoms of mental disorders.
The Public Story. After distillling the "expert story" about child mental health, FrameWorks researchers set out to distill the "public story" about this issue. This research is based on theories that argue that individuals use cognitive structures called cultural models to make sense of their social worlds [6]. As noted anthropologist and sociologist Evan Goffman wrote in his 1967 book: Cultural models can be seen as systems of existing and consistently implied relationships, propositions, and assumptions that are implicitly applied to make sense of and organize the information and experiences that individuals are presented with. Functionally, these models are what allow us to make sense of an infinite range of incoming information and experiences expeditiously enough to interact seamlessly with the individuals and situations that we encounter [8].
To understand the cultural models that Americans use to understand mental health, mental illness, and child mental health, FrameWorks conducted a series of in-depth open-ended interviews with 20 members of the American public in Dallas, Texas, and Cleveland, Ohio, and an additional set of "on-the-street" interviews in three other U.S. locations. The sample included 10 men and 10 women of various ages, races and ethnicities, and political identifications. While the sample was not nationally representative (nor was it intended to be), participants were selected to ensure that the cultural models identified represented shared, or cultural, patterns of thinking. Previous research shows that members of the same culture share many of the same beliefs and attitudes about social issues-even when they differ according to race, ethnicity, socioeconomic background, and other criteria [4].

Dominant cultural models
Analysis of the interviews revealed the following cultural models about mental health, mental illness, and child mental health. The FrameWorks Institute describes these models as "dominant" because of their pervasiveness throughout participants' talk. The findings are summarized in Conflicting Models of Mind in Mind, a report published by the FrameWorks Institute in 2009 [7].
• Mental health is tantamount to emotional health. Participant discussions revealed an assumption that good mental health results from experiencing positive emotions and coping with negative ones. Poor mental health, in turn, was seen to result from failing to "deal with" negative emotions. Participants also believed that individuals are responsible for controlling their emotions and, by extension, their mental health.
Mental health, then, is seen as an individual issue, not an environmental or contextual one. This individualistic, or "mentalist," model is common in American culture. It reflects a widely shared assumption that people's outcomes are completely under their control and determined by hard work and self-discipline. When applied to issues related to child mental health, this model reduces the complex interactions between individuals and environmental and systemic factors to individual control and undermines efforts to advance systemic solutions to promote child mental health. If mental health is determined by an individual's emotional state and controlled by his or her ability to control emotions, then remediating problems is an individual's responsibility and can be accomplished through effort and discipline. Contextual supports and interventions are difficult to see as important when thinking in this way.
• Mental illness is a "chemical imbalance" in the brain. While participants saw mental health as an issue of emotions, they understood mental illness as caused by the presence or absence of certain chemicals in the brain. As such, participants saw mental health as a condition that can be controlled by the individual and mental illness as a condition over which individuals have no control. Some participants thought people might benefit from medication, but participants also assumed that the chemicals that result in mental illness are genetic and, as such, are "hard-wired" into the brain. Pharmaceuticals, they reasoned, are the only way to rebalance these chemicals.
• Children either do or do not experience mental health. Participants spoke in multiple and contradictory ways about child mental health and illness. Some said, for example, that children do not experience mental health because their brains work in different ways than adult brains do. Children, they said, cannot "really" have mental health because they "are not sufficiently aware of, do not have the ability to remember, and do not have enough understanding of their emotions to experience either good or poor mental health." Participants also said children-especially the very young-have less ability to understand and remember emotions, which they understood to determine whether children can experience meaningful mental states. Other participants, meanwhile, said children do experience mental health but in less complex ways than adults do. Participants compared children to "little adults" who live in "simpler worlds" with "fewer variables" (i.e., parents, the home environment, and the classroom). Reasoning from this assumption, children's narrow worlds limit their ability to experience extreme states of mental health or illness.

Implications of dominant cultural models
These dominant cultural models have significant implications for advocates and experts who are seeking to build public understanding and support for systemic solutions. Communicators who cue these models, even if inadvertently, are likely to depress public support for child mental health policies and programs. FrameWorks compares these cultural models to a swamp -a rich, wild, untamed ecosystem where advocates' messages can get "lost" in a thicket of unproductive or competing assumptions, attitudes, and beliefs about children, families, and mental health, or "eaten" by stronger, counterproductive attitudes and beliefs about these subjects. The swamp is meant to convey the complexity, depth, and multiplicity of public thinking on social and scientific issues and the fact that much of this thinking takes place at an implicit level. The swamp can help communicators see how certain ways of thinking are productive for communicating certain messages and others unproductive in creating openings to consider new information. The swamp metaphor is not meant to imply that certain ways of thinking are "right" and others "wrong." Culture is never right or wrong, but certain cultural understandings can facilitate the communication of ideas while others may block or impede the communications process.
Advocates and experts who have a map of the swamp of cultural models about child mental health will be better able to make their way through it and more successful in moving their messages and issues into the public discourse with fidelity. Their messages will not get lost in the swamp or "devoured" by other counterproductive models about child mental health-the "gators" in the swamp. The following are key implications of the swamp for those communicating about child mental health, as explained in detail in a 2009 report by the FrameWorks Institute [7].
First, if the public believes that emotional health is tantamount to mental health, and that children do not experience emotions in the same way that adults do, then people will question whether children do in fact experience mental health. This makes it difficult to effectively communicate about the importance of policies and programs that promote child mental health and for funding for such actions. This is especially true in conversations about very young children, who are perceived to have even less capacity to experience emotions.
Second, if young children cannot remember experiences, then the long-term effects of those experiences on mental health become difficult to conceptualize. This can make it difficult for people to grasp the importance of programs that promote child mental health at early ages, which experts say is deeply affected by the experiences children have in their early years.
Third, if people believe that child and adult mental health are essentially the same, then they will have difficulty understanding the need for child-specific treatments or interventions for particular developmental periods and will gravitate toward those that encourage children to take responsibility for coping with negative emotions. This is something that was frequently seen in FrameWorks research.

Recessive cultural models
Analysis of cultural models interviews revealed the following recessive cultural models about mental health, mental illness, and child mental health [9]. FrameWorks describes these models as "recessive" because they came up less often than dominant models and were pushed to the cognitive periphery when a more dominant model came into thinking.
Some participants acknowledged that a child's environment can influence whether he or she experiences good or poor mental health. Environmental factors, however, were most frequently restricted to parental behavior and home life. Participants often overlooked other factors, such as relationships with other caregivers, housing quality, neighborhood and community resources, child care and school quality, and the "built environment." Some participants understood that stress, and specifically prolonged or repeated stress, can contribute to mental health conditions in children. As above, these participants had a narrow understanding of the source of stress; they saw it coming mainly from home and school environments. Some also talked about how children who experience strong "foundations" (i.e., nurturing and responsive interactions with caring adults during their early years) are more likely to experience good mental health and those who have poor foundations are more likely to have poor mental health.
Participants also defined the quality of a child's mental health as his or her level of functioningthe ability to participate in developmentally appropriate activities in typical ways in family and community environments. This is consonant with the views of experts, who assess a child's mental health in part by his or her functional and developmentally appropriate capabilities.

Implications of recessive cultural models
Swamps are not entirely dangerous places. In addition to giant reptiles, venomous snakes, and murky bogs, they also have things of great beauty, richness, and utility, like orchids and rare medicinal plants. The same is true for the "swamp" of cultural models of child mental health. This cultural ecology has useful thought patterns that, if activated, can help in the communications of child mental health science and increase the accessibility of key messages from the field of child development. These more recessive models represent opportunities for advocates to help members of the public better understand the science behind child mental health and build support for needed policies and programs.
For example, the fact that, with the right cues, people are able to appreciate that a child's environment can affect his or her mental health is important because it opens the door for people to access and apply scientific understandings of the influence of environmental factors such as nutrition, supportive relationships, housing quality, access to health and child care, and others, on child mental health. Even so, participants had a very limited understanding of which environmental factors do in fact affect mental health; they tended to focus narrowly on parents and home life and overlooked the effects of other environmental and systemic factors that shape mental health and development more generally. Also important is the fact that participants were able to understand the effects of stress-again, at certain points in their discussions-and particularly prolonged, severe stress, on children's mental health. And finally, the fact that participants could think of child mental health in terms of developmentally appropriate functioning is promising because of the consonance between this way of thinking and the science of child mental health.

Gaps in understanding
The following section summarizes the gaps between expert and public understandings of child mental health [4]. These gaps represent specific challenges for child mental health advocates to address through strategic communications and framing. Frames, as discussed in subsequent sections of this chapter, have proven effective in bridging these gaps and deepening understanding of key concepts from the field of child mental health and increasing support for a new set of solutions.
• Experts blur the line between mental health and mental illness, but the public see these as separate and distinct.
• Experts support a wide range of means to prevent and treat mental health issues and disorders, but the public has narrow understandings of effective treatments depending on whether they are thinking about mental health or mental illness. They see individuals as responsible for developing good mental health and drugs as a way to cope with-but not cure-mental illness.
• Experts believe that child mental health is a real phenomenon that requires attention, but the public frequently does not share that unequivocal conviction or the experts' sense of the salience of the issue.
• Experts have a broad understanding of the environmental factors that shape mental health, but, for members of the public, this view is limited to home and family.
• Experts believe that the genetic influence on mental health and illness is contingent on environments and experiences, while the public sees genes and the chemicals they shape as "set in stone."

The media story
Understanding cultural models about child mental health, and knowing how they differ from expert views, is a key first step in creating more effective strategies to bring science to public thinking. Understanding how the media frames the issue adds an important layer of detail about public thinking and can be a lever for shifting and expanding it. The media is a primary source of information for Americans [10] and plays a powerful role in setting and reinforcing cultural models. As explained in an earlier FrameWorks study on this subject: "Common media frames lead to common interpretations both because of their standardized content and due to the fact that repeated exposure to these frames activates and engrains a set of interpretations that become highly practiced and easy to use in 'thinking' information on an issue" [10]. Advocates and experts who understand how the media influences cultural modelsspecifically how they amplify some ways of thinking and suppress others-will be better able to navigate their messages through the swamp of public thinking.
To map media frames of child mental health, FrameWorks, in partnership with the Endowment for Health and the Center on the Developing Child at Harvard University, conducted a systematic analysis of articles published in major newspapers between May 2008 and May 2009. The analysis identified dominant news frames and examined how those frames affect, and are affected by, public thinking.
Overall, the findings showed that the media rarely cover children's mental health. Instead, the media is more likely to cover mental illness, but in ways that are likely to cue unproductive cultural models. For example, many articles that were included in the sample painted detailed "pictures of vivid cases" of disruptive child behavior. One story, published in the Omaha World-Herald in 2008, chronicles a mother's decision to leave her 11-year-old son in a U.S. hospital. The story describes how the boy tore the house apart, refused to take his medication, tortured the family pet, and physically abused his brother. The mother felt that placing her son in state care was "the only way" to help him [10]. Articles that describe children's disruptive behavior in this level of detail are likely to trigger the public's sense of hopelessness about mental illness in general and children's mental disorders in particular.
When presented with such vivid accounts of severe issues, members of the public are likely to see these problems as caused by genetic factors, and "set in stone" and thus incurable [10]. Reasoning from this perspective, it is difficult to see solutions as tenable and hard to engage in the issue.
These articles also present details about the difficulties faced by families in accessing care but exclude, to a large extent, explanations about how and why children develop mental illness or about specific solutions and how they work to address issues and improve outcomes. This suppresses public thinking about programs and policies that can promote child mental health. "Without coverage that strategically frames the science of child mental health, and concretizes and specifies policies that involve all citizens, child mental health outcomes will continue to be perceived by the public as an unfortunate but unsolvable problem that affects a small subset of Americans," the study found [10].
On the other hand, researchers did find some promising aspects of media coverage of child mental health. To start, the media focus on issues of access and adopt a systemic perspective in these discussions-that is, when discussing access issues, media coverage tends to focus on the structural factors that impede or facilitate a family's ability to access treatment. This is particularly true of coverage of issues facing marginalized populations. Low-income families, or those of racial and ethnic minority groups, are frequently portrayed as facing structural factors that make it difficult for them to access the care they need for a child with a mental health issue [10]. These more systemic or "thematic" stories likely encourage readers to adopt a more structural and contextual perspective and move beyond what FrameWorks calls the Family Bubble-the widely shared assumption that parenting behaviors determine children's outcomes and the difficulty in seeing the wider set of factors that affect parents. Despite these more positive aspects of the media coverage, the report concludes, "The likely impact of the media's definition of the problem is to deepen the public's sense that children's mental health problems are fundamentally intractable and cannot be addressed through programs or policies that support these children and their families" [10].

Redrawing the map
To help advocates and experts navigate the swamp of public thinking about child mental health, FrameWorks designed and tested framing strategies for their ability to increase public understanding of child mental health issues and support for a wide range of evidence-based solutions [11]. As part of this work, FrameWorks tested the effect of six values on public thinking. Values are frame elements that orient readers to deep beliefs or principles they consider worthy and important. Four of the six values were chosen because they had performed well in prior research on early childhood development. These values were collective prosperity (we will all prosper if we promote child mental health); ingenuity (we can tackle difficult problems like child mental health with innovative solutions); future progress (we must devote resources to children because they are the key to future social progress); and responsible management (we have a responsibility to make careful decisions about how best to support child well-being). The survey also tested two values that were common in advocacy literature: vulnerable children (we must take action to support children because they are society's most vulnerable members) and health (investing in children's well-being is important because health is an important social goal). In 2010, FrameWorks followed this initial survey experiment with a subsequent one that tested two additional values: prevention (the power of prevention-focused actions in improving long-term outcomes for children and society) and interdependence (the notion that children's mental health affects the well-being of all of society) [11].
The surveys found that two values-prosperity and ingenuity-improved respondents' understanding of the importance of child mental health and elevated their support for evidence-based policies [11]. The value of prosperity was the most effective in shifting support for children's mental health policies. The value of ingenuity, meanwhile, increased efficacy by helping to counter the public's default assumption that little can be done to improve outcomes for children.
To help advocates and experts use these frames in their communications, FrameWorks developed sample iterations of these values in a report it produced in 2010 [3]. These examples follow: Child well-being is important for community development and economic development. Young children with strong mental health are prepared and equipped to develop important skills and capacities that begin in early childhood. These children then become the basis of a prosperous and sustainable society-contributing to things like good school achievement, solid workforce skills, and being strong citizens. When we ensure the healthy development of the next generation, they will pay that back through productivity and responsible citizenship. Innovative states and communities have been able to design high-quality programs for children, which have solved problems in early childhood development and shown significant long-term improvements for children. As a society, we need to invent and replicate more effective policies and programs for young children.
FrameWorks also studied the effects of "explanatory metaphors"-metaphors that enhance understanding of scientific concepts by comparing them to concrete, ordinary objects, and processes-on public thinking. This research found that comparing child mental health to the "levelness"-of a table or piece of furniture-helped members of the public understand the concept and reason about solutions in productive ways [12]. This metaphor in particular was effective in communicating that children's mental health is influenced by environmental factors and must be addressed with actions that address environments and experiences. It also tapped into people's recessive connection between child mental health and functioning. People reasoned that if a table is unstable it would not function well and that a child's mental health works in the same way. If a child is exposed to abuse, violence, or neglect, or does not have access to nourishing foods or quality health and child care, then his or her mental health may not be as "level" as it would be if he or she grew up in a more stable environment. This metaphor counters the public's assumptions that children's mental health is influenced entirely by parental behaviors.
The metaphor also takes the onus for achieving good mental health off of individual children. Tables, after all, cannot level themselves. Likewise, children cannot solve mental health problems on their own. At the same time, the metaphor conveys that interventions and treatment can promote stability and function. Putting a piece of cardboard under the leg of a wobbly table will increase its stability, as will moving it to more level and stable ground. Interventions work the same way; they have the potential to help children achieve better mental health. This counters the public's fatalistic attitudes, which presuppose that mental illness is genetic and therefore incurable. A sample iteration from the 2010 FrameWorks report follows [3].
Scientists say that children's mental health affects how they socialize, how they learn, and how well they meet their potential. One way to think about child mental health is that it's like the levelness of a piece of furniture, say, a table. The levelness of a table is what makes it usable and  able to function, just like the mental health of a child is what enables him or her to function and do many things. Some children's brains develop on floors that are level. This is like saying that the children have healthy, supportive relationships and access to things like good nutrition and health care. For other children, their brains develop on more sloped or slanted floors. This means they are exposed to abuse or violence, have unreliable or unsupportive relationships, and do not have access to key programs and resources. Remember that tables cannot make themselves level-they need attention from experts who understand levelness and stability and who can work on the table, the floor, or even both. We know that it's important to work on the floors and the tables early, because little wobbles early on tend to become big wobbles later.
These findings led to the creation of a "core story" of child mental health-a master narrative that advocates and experts can use to help the public understand what child mental health is and what needs to be done to promote it. This core story begins with an appeal to the values of prosperity and ingenuity and includes the "levelness" metaphor. Leading communication materials with messages about how our future prosperity depends on children who have good mental health and about our country's history of tackling difficult problems with innovative solutions primes the public to productively consider the policies and programs needed to promote good child mental health. Using the Levelness metaphor to explain the science behind and solutions to child mental health also supports productive thinking. These are the toolsthe flashlights, the compasses, the protective gear-that communicators need to navigate through the "swamp" of public understanding and get their messages through to the public in productive ways. For more detail about these tools and the research that supports them are found in website visit www.frameworksinstitute.org.