Poor MH Care for Children Called National Crisis

Carter introduced keynote speaker Dan Offerd, M.D., director of the Canadian Center for Studies of Children at Risk. He reminded attendees about the prevalence of mental health problems in children.

“Community surveys show that between 17 percent and 22 percent of children and adolescents have clinically significant emotional and behavioral problems,” said Offerd.

He also emphasized that mental illness occurs along a continuum. “Most of the childhood disorders we are concerned about extend into adulthood, and most of the adult disorders you and I are concerned about have their roots in childhood.”

Offerd discussed “protective factors” in children’s mental health, which must be encouraged and fostered by the adults in their lives.

For instance, when a child with emotional or behavioral problems has a good relationship with an adult inside or outside the home, or if he or she is good at either a particular school subject or an extracurricular activity, the child has better mental health.

Offerd spoke of the importance of “civic communities,” where parents not only take responsibility for their own children, but for other children as well. In a civic community, Offerd said, leaders do not marginalize children with mental health problems, but instead engage all children in community activities.

Finally, Offerd urged all those who serve children to use their hearts and heads. “You and I must act with informed compassion, which will make a huge difference in children’s lives,” he said.

There are many barriers to good mental health for children, according to Peter Jensen, M.D., director of the Center for the Advancement of Children’s Mental Health in New York.

One barrier is thrown up by the “atheists and agnostics” of mental health problems, who either don’t believe that mental illnesses exist or think they are extremely rare, said Jensen, who is the Ruane Professor of Science in Child Psychiatry at the Columbia University College of Physicians and Surgeons.

Yet another barrier is poor communication between clinicians and parents. In a nationwide study of 200 pediatricians and 300 parents conducted two years ago by the Center for the Advancement of Children’s Mental Health, Jensen found that parents and pediatricians were like “two ships in the night” when discussing mental health problems of child patients.

“When we asked pediatricians how often during routine visits they spoke with the parents about the mental health of their child, 77 percent said they did all or most of the time,” said Jensen.

However, when parents were surveyed about how often the topic of their child’s mental health came up in discussions with their pediatricians, 44 percent of parents said the pediatricians never asked.

In addition, while 42 percent of pediatricians said they believed that mental health problems were fairly common among children and adolescents, only 21 percent of parents said they were common.

“If you go to a doctor who says mental health disorders are fairly common, the child [with mental health problems] is more likely to be identified,” said Jensen, who added that identification of children with mental health problems hinges on good communication between parents and pediatricians.

Finding the early warning signs, or indicators, of emotional or behavioral problems in children with current mental health needs is one of Jensen’s tasks in his work with the Surgeon General’s Federal Working Group on Children’s Mental Health.

“The goal from the federal perspective is that the indicators will go to professional groups to be used in strategic settings,” said Jensen.

The indicators must not be stigmatizing to the children whom professionals are trying to help, must be culturally appropriate, and must be communicated in a straightforward manner, said Jensen.

Other issues to consider when developing indicators, explained Jensen, are whether there should be separate indicators for boys and girls and how to develop indicators for children under the age of 3 years, for instance.

In addition to finding ways to identify children with mental health needs, symposium attendees listened and participated in talks about how to improve collaboration between systems of care for children and adolescents.

Beth Stroul, M.Ed., a senior consultant to the national evaluation of the federal Comprehensive Community Mental Health Services for Children and Their Families Program, discussed the characteristics of systems that successfully help children and adolescents with mental health problems.

“Services should be comprehensive, individualized, provided in the least-restrictive setting, and coordinated at both the system and service-delivery levels,” said Stroul. “They must involve family and youth as partners and emphasize early identification and intervention.”

Stroul explained that high-quality systems of care provide a range of treatments and services guided by a philosophy. “The goal is to provide state-of-the-art, effective clinical services and supports,” she said.

These services often include outpatient psychotherapy, residential services, and school-based interventions such as counseling and intensive case management, for instance.

For systems of care to be effective, Stroul said, they must work together and not at cross-purposes when serving children with multiple needs.

An “explosion” of the recognition of mental health problems in one such system—primary care—has caused a shift of responsibility for recognition and treatment of children away from the mental health care system, according to Kelly Kelleher, M.D., M.P.H.

Kelleher is the Staunton Professor of Pediatrics and Psychiatry at the University of Pittsburgh School of Medicine and director of the Child Services Research and Development Program at Children’s Hospital and the University of Pittsburgh.

“Primary care providers are now responsible for the majority of medical expenditures on psychotropic drugs,” said Kelleher.

However, there have been problems with overdiagnosis and underdiagnosis of children with certain mental disorders, such as attention-deficit/hyperactivity disorder (ADHD) by pediatricians and family practitioners.

Moreover, he pointed out, “Many schools and parents actively seek ADHD medications for behavior control in children and adolescents with disruptive behaviors, and such services are often the only types reimbursed easily for children with mental disorders.”

Kelleher cited time restrictions and communication problems as two major barriers to providing good mental health services to children during a pediatric visit.

Another problem is that there is no tracking system to ensure that referrals from primary care physicians actually take place, according to Kelleher. In one study, he said, in children with new psychosocial problems, 20 percent were referred for mental health treatment at the index visit and just 47 percent of these children saw a mental health professional during the six-month follow-up period. Pediatrics originally developed from an infectious-disease treatment model, said Kelleher, which is not ideal for long-term treatments for emotional and behavioral problems.

However, he continued, some chronic disease models of care are better for mental health problems. “These models talk about patient engagement and how to get patients to feel empowered to take care of their issues. They involve family support systems and group well visits,” said Kelleher.

Other suggestions that Kelleher offered to improve the effectiveness of systems of care were to have families carry medical records with them from clinician to clinician so there is continuity of medical information, and to have health plans track patients through registries over time.

“We have to think about multiple levels of interventions targeted toward patients up to payers and communities,” said Kelleher. ▪