By
Arline Kaplan © 2002 (All Rights Reserved)
California
has failed dismally at providing mental health services to disturbed youth,
many of whom are dropping out of school and crowding jails and mental hospitals,
a state watchdog agency recently warned. But California is not alone.
In Massachusetts, advocates of home-based treatment for mentally ill children
announced plans to sue the state for allegedly forcing hundreds of children
into unnecessary and lengthy hospital stays. In Colorado, a shortage
of residential services for children with serious mental illness resulted
in some children being sent out of state for treatment.
"What
we are seeing in many communities is an increased number of children and adolescents
ending up in emergency rooms, and the hospital [staff] having a difficult
time finding appropriate placement for them in an acute inpatient setting,"
he said.
Even
when kids are placed in inpatient or residential facilities, in many cases,
there is a lack of step-down programs, such as outpatient care, Covall added.
The
New York Times, for example, has reported on the "stuck kid"
problem in Massachusetts (Goldberg, 2001).
"There
are the children who must wait for hours in emergency rooms while in full-blown
psychiatric crises. There are the 'border kids,' children stuck for
days or weeks, or in extreme cases, months, in pediatric wards because there
is no place for them in a psychiatric ward or hospital. There are the
'wait-listed kids,' waiting months for outpatient therapy or case management.
And there are the 'stuck kids,' themselves, usually about 100 of them at any
time in the state, according to official figures, who are ready for discharge
from psychiatric hospitals, but cannot leave for lack of outside treatment
programs," the article said.
Among
several factors contributing to these situations, Covall said, is managed
care, which has put on pressure to reduce lengths of stay, reduce hospitalizations
and reduce reimbursement rates. As a result, some facilities have closed.
In
a study looking at managed care's possible impact on psychiatric inpatient
care for children and adolescents from 1988 to 1995, researchers found a 44%
decline in mean length of stay and a 23% decline in total number of days of
care provided to children and adolescents with primary psychiatric diagnoses
in general hospitals (Pottick et al., 2000). They warned that further penetration
by managed care, especially into the public insurance system, along with changes
in Medicaid policy, "could undermine inpatient resources."
Medicaid,
a federal-state program, is the primary public funding source for mental and
substance abuse services for children and adolescents. Covall explained
that many state Medicaid programs have moved into managed care, putting additional
pressure on resources.
Although
Medicaid has the Early and Periodic Screening, Diagnosis and Treatment program
(EPSDT) that requires children to receive medically necessary services for
physical and mental illnesses and conditions, the program has not been fully
implemented in many states, Covall said, so a lot of kids' needs are not being
met.
Children
and adolescents who fall through the cracks, Covall said, often end up in
the juvenile justice system, which has become "a de facto part of the
mental health system."
In
Chicago, researchers studied 1,829 children in juvenile detention centers,
and found that 75% of the females and 66% of the males had one or more psychiatric
disorders (Health and Human Services, 2001). Moreover, in a survey commissioned
by the National Alliance for the Mentally Ill (NAMI), more than one-third
of parents said their children were placed in juvenile justice because needed
mental health services were not available (Vitanza et al., 1999)
Fragmentation
Another
pervasive problem in providing adequate mental health care, Covall said, emanates
from the multiplicity of programs that impact kids: schools, juvenile justice,
foster care, the welfare system and Medicaid.
"Each
of those programs provides some supports to the kids, but it is done in very
haphazard way, so in many cases the kids don't get the coordinated set of
services that they need," he said.
California's
Little Hoover Commission report, Young Hearts & Minds: Making a Commitment
to Children's Mental Health, also clearly delineated the fragmentation.
The commission, an independent state oversight agency, said California is
spending over $56 billion annually on a "crazy quilt of entitlement,
categorical and pilot programs. No services are holistic. No one
is accountable for how decisions affect the overall quality of life of children
or their families…Disparate programs translate into little or no continuity
of care as children age or their needs evolve.
Aware
of the fragmentation challenges, more than 200 people from mental health,
child welfare, education and juvenile justice agencies and organizations gathered
at the 17th annual Rosalynn Carter Symposium on Mental Health Policy
to consider how to redesign mental health care for children. Mary Jane England,
M.D., president of Regis College and a former president of the American Psychiatric
Association, moderated a panel on redesigning systems and assessing needs.
Other panelists included Carl Bell, M.D., University of Illinois; James Harris
Jr., M.D., Johns Hopkins University School of Medicine; Kelly Kelleher, M.D.,
M.P.H., University of Pittsburgh School of Medicine, and Beth Stroul, M.Ed.,
author of Children's Mental Health: Creating Systems of Care in a Changing
Society (1996).
After
the panel's presentations, work groups also offered suggestions as to what
could be done.
Opinions
presented ranged from we have a system and it needs to be renovated to the
system is so broken it has to be redesigned, said Gregory Fricchione, M.D.,
executive director of the Carter Center's Mental Health Program, associate
professor of psychiatry at Harvard Medical School and head of the medical
psychiatry service at Brigham and Women's Hospital.
Among
suggestions presented by the panelists and work groups were:
Create
a common record that could go with the youth from one system to another,
so, for example, a school guidance counselor's or teacher's observations
could be communicated to the child's pediatrician and vice versa.
Include
youth and their families in the planning process.
Focus
on prevention and early intervention as an economic and societal "bargain"
and provide prevention/intervention services to a broad population of
youth.
Provide
better cross-system case management.
Have
all child-serving agencies sign on to a treatment plan for accountability.
Identify
positive replicable models.
Create
ongoing, local strategic plans for a mental health continuum of care for
children.
Collaborate
to identify disincentives to care such as reimbursement issues and turfism.
Align
financial incentives for evidence-based care.
Signs
and Symptoms
Another
panel at the Carter Center focused on signs and symptoms of mental health
problems in children as a follow-up to the U.S. Surgeon General's report on
children's mental health (Health and Human Services, 2001). That report
emphasized that people involved in the care of children need to know how to
identify early indicators of potential mental health problems.
In the United States, one in 10 children and adolescents suffer from mental illness severe enough to cause some level of impairment, but only about one in four are really identified and get care in any timely way, said panel presenter Peter Jensen, M.D., director of the Center for the Advancement of Children's Mental Health and Ruane Professor of Psychiatry at Columbia University. Jensen is part of a team developing a set of indicators of mental health problems similar in concept to "the 10 warning signs of cancer."
"A
number of scientists, policymakers and family advocates are coming together
to look over some of the very best data sets we have across the United States
and other countries [to identify] the best predictors of a child having a
mental health problem that is not being recognized," he said in an interview
A
federal multiagency task force, under the direction of Kimberly Hoagwood,
Ph.D., associate director for Child and Adolescent Research at the National
Institute of Mental Health, is overseeing the project. The task force
has awarded a contract to Columbia University to identify the potential indicators.
"After
we identify the possible indicators, they have to be run through a public
vetting process to make sure that they are acceptable, understood, palatable
and that they are used in a child-friendly way," he said. "This
process is quite complex: indicator that might work well say in upper middle-class,
Caucasian families might not work well with inner-city or poor families.
You might have some indicators that work well with pediatricians, but are
misunderstood by the public."
Another
part of the task is to produce a report for the federal government with the
potential indicators that can be used generally and by specific groups and
a series of recommendations for federal follow-up.
Shortage
of Trained Professionals
A
common concern expressed by Covall, participants at the Carter Symposium and
authors of California's Little Hoover Commission report was the lack
of trained professionals.
From
his vantage point at NAPHS, Covall said there is "a serious shortage
of child and adolescent psychiatrists, and a shortage overall in psychiatric
professionals especially those who would work in residential programs."
The
vacancy rate for mental health professional positions in California exceeds
30%, according to data in the Little Hoover Commission report.
In Northern California, the report authors added, it can take almost a year
and a half to fill vacancies for psychiatrists and psychologists.
In
the wake of the Sept. 11 attack on America, the need for trained professionals
becomes even more intense, Charles Curie, M.A., A.C.S.W., administrator for
the Substance Abuse Mental Health Services Administration, told participants
at the Carter Symposium
Since
primary care physicians and pediatricians are usually the first medical contacts
for children, attention is being given to their training, participants at
the Carter symposium said. Some of that training might be directed toward
resolving some major disconnects between pediatricians and parents.
Jensen gave an example from his unpublished study where 300 parents and 200
were surveyed about their perceptions of each other. Pediatricians
said that pretty much all or most of the time they asked parents whether their
child had any mental health problems. In contrast, parents, on average,
"felt like it happened, never."
While
most of the presentations at the Carter Symposium focused on mental health
policy and resource needs, the kids, who suffer with psychiatric disorders,
did have an opportunity to speak, Fricchione said. A panel of four teenagers
talked about their personal experiences in dealing with emotional and behavioral
problems.
"They
talked very deeply about problems with teachers who didn't understand them,
peers who were against them. They talked about the kinds of services
they received from mental health professionals," Fricchione said.
"They pointed out that adults (parents, teachers, mental health professionals)
have to get real with the kinds of problems that kids like them face and to
talk with them at their level. But they all had stories of hope.
They indicated we all have to keep a level of hope and we have to listen to
the kids, themselves, and what they think their needs are.
References
Goldberg
C (2001), Children trapped by mental illness. The New York Times, July
9.
Health
and Human Services (2001), Report of the Surgeon General's Conference on Children's
Mental Health: A National Action Agenda. Available at www.surgeongeneral.gov/cmh/childreport.htm.
Accessed Nov. 10, 2001.
Little
Hoover Commission (2001), Young Hearts & Minds: Making a Commitment to
Children's Mental Health. Available at www.lhc.ca.gov/lhcdir/report161.html.
Accessed Oct. 25, 2001.
Pottick
KJ, McAlpine DD, Andelman RB (2000), Changing patterns of psychiatric inpatient
care for children and adolescents in general hospitals, 1998-1995. Am
J Psychiatry 157(8):1267-1273.
Stroul
B (1996), Children's Mental Health: Creating Systems of Care in a Changing
Society. Baltimore: Paul H. Brookes Pub Co.
Vitanza
S, Cohen R, Hall LL (1999), Families on the Brink: The Impact of Ignoring
Children with Serious Mental Illness. Prepared for the National Alliance
for the Mentally Ill.
(PT
0102)
Viewers, Your Help Is Needed:
I am a freelance medical journalist. Some of the articles posted on this Web site were originally written for health care professionals, but I believe patients/consumers may also find value in the articles. Many of us who have chronic or life-threatening health problems become experts on them. For that reason, I have kept the rights to electronically post these articles.
Additionally, I am developing new stories specifically for this site. It is my intention to offer you high-quality, well-researched information. Because this site accepts no advertising, your financial support is needed to continue this user-sponsored service.
I welcome your comments, suggestions and financial help. You can send voluntary contributions to, or contact me at:
HealthRising
Arline Kaplan
P.O. Box 3644
Costa Mesa , CA 92628