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A D V O C A C Y M O R N I N G R E P O R TJ E S S I C A M I L L E R

D E C E M B E R 7 , 2 0 1 2

ACCESS TO CHILD MENTAL

HEALTH SERVICES

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THE CASE:

6 y/o boy brought in for behavior issues

Started kindergarten this year, mother has beencontacted frequently by school for concerns about

the patients behavior hitting other children in the classroom

often wandering around the classroom and will notlisten to teacher

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THE CASE:

At home:

Spanish is spoken in the home, and most instructionat school is in English

Parents separated 2 years ago patient began hitting sister at home soon after

father left

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THE CASE:

PMH: Term birth, no complications surrounding pregnancyor birth, no past hospitalizations

Medications: none

PSH: none

Social: Lives with mother and older sister age 8. Motherspeaks Spanish only. Father has visitation 2 days per week.Entire family uninsured, mother says she started a Medicaidapplication for the patient, but hasnt heard back

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THE CASE:

Physical Exam:T: 36.7 Wt: 20.1 kgGEN: crawling over chairs, messing with lamp in cornerHEAD: normocephalic, atraumaticEYES: EOMI, PERRLTHROAT: OP pink, moist, uvula midline, tonsils normal appearingNECK: supple, FROM, no masses or lesionsCHEST: CTABCV: RRR, no murmursADB: soft, non-distended

NEURO: grossly normal

Vanderbilt screen completed at last clinic visit and is highly positiveby both mother and teacher across inattentive, hyperactive,anxiety/depression areas

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THE QUESTION:

W H A T M E N T A L H E A L T H R E S O U R C E S A R E A V A I L A B L E T O T H I S F A M I L Y ?

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SCOPE OF THE ISSUE

Almost 1/5 children in the US suffers from a severemental health disorder at some point in life

Only 20-25% of affected children receive treatment

(Mental Health- A Report of the Surgeon General,1999)

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SCOPE OF THE ISSUE

From CDC NHANES

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WHY DOES THIS ISSUE MATTER?

Without intervention many child mental healthdisorders:

continue into adulthood

are associated with higher rates of: poverty

school failure

poor employment

higher utilization of healthcare resources

poor social mobility substance abuse

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WHAT ARE THE BARRIERS TO CARE?

Systems Barriers

Patient Perceptions of:

Structural Barriers Mental Health Disorders

Mental Health System

Socioeconomic and Racial Disparities

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STRUCTURAL BARRIERS

Lack of providers for Medicaid/ Uninsured

Insufficient payments

Lack of payment to PCPs/ mental health providers for visits

with parents only Lack of payment to PCPs for time spent

coordinating care

Inadequate mechanisms of communication

between primary care, mental health and schoolproviders

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CHILD/ ADOLESCENT PSYCHIATRY

PROVIDER SHORTAGE

7418 nationally (2009)

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PATIENT PERCEPTIONS

35% identified barriers

Structural

Too expensive

Dont know where to go

Mental Health Disorders

Problems not serious

Mental Health Services

Lacked confidence in

who recommended help People trusted most did

not recommend help

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SOCIOECONOMIC AND RACIAL

DISPARITIES

Minorities are more likely to experience:

food insecurity

neighborhood social disorganization

chronic exposure to racism

More likely to experience violence in the home andin the community

community violence exposure linked to post-traumaticstress disorder, depression, externalizing behaviors

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SOCIOECONOMIC AND RACIAL

DISPARITIES

Rates of maternal depression in racial minoritiesmay be as high as 30-40%

Higher rates of mental disturbance in the juvenilejustice system and child welfare system

These systems 50-70% minority children

Lower rates of psychotherapy and psychotropicmedication use

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WHAT CAN PEDIATRICIANS DO ABOUT

ALL THIS?

In the clinic

In the community

In the legislature

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SOLUTIONS: THE PRIMARY CARE

SETTING

AAP task force on mental health has emphasizedthe importance of the primary care pediatrician inmental health care

Important role given child psych shortage

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SOLUTIONS: THE PRIMARY CARE

SETTING

Add questions about mental health service use,mental health disorders to new patient visits

Incorporate discussions about behavior and moodinto well child visits

Be aware of high risk populations: Foster care

Parents in military/ national guard LGBT adolescents

Significant psychosocial stressors

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SOLUTIONS: THE PRIMARY CARE

SETTING

Assess family readiness to address mental health issues

Address stigma about mental health issues

Assure families about the confidentiality

Use of the primary care for treatment of commonmental health disorders

ADHD, Depression, Anxiety, Substance abuse

Seek feedback about community mental healthresources from families

Ask family to sign consent to share treatment informationat time of mental health referral

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SOLUTIONS: IN THE COMMUNITY

Apply a population perspective to understandmental health needs Early intervention referrals, high school graduation rates,

substance abuse rates, teen pregnancy rates, suicide and

homicide rates

Inventory the mental health resources in thecommunity

Enhance communication between medical,mental health and school resources Each of these have the tendency to operate separately

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HOW TO FIND LOCAL RESOURCES

The Mental Health Binder

Agencies

Services offered

Age range Insurance accepted

Spanish or not?

Parteras at South Main Clinic

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A FEW LOCAL RESOURCES

Valley Mental Health www.vmh.com, 888-949-4864 Inpatient/Outpatient mental

health services Medicaid

Fourth Street Clinic www.fourthstreetclinic.org/servi

ces/programs outpatient Uninsured/homeless

Polizzi Clinic

http://polizziclinic.org, 801-449-0752 Uninsured New intake 3rd Sat. each

month

SLC Division of Youth Services

www.slcoyouth.org, 385-468-4500

Short term free counseling,youth and parent groups

Highland Ridge Hospital www.highlandridgehospital.co

m 1800-821-HELP Medicaid Inpatient services

The Childrens Center www.tccslc.org, 801-582-5534 Children

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SOLUTIONS: IN THE COMMUNITY

Grant helps Childrens Center expandwork with kids with post-traumatic stress

Salt Lake Tribune, November 24, 2012

what looks like ADHD may really be achilds reaction to experiencingtrauma

$1.6 million over four years

Treatment of 400 additional children Focus on refugee, military, foster care

families

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SOLUTIONS: ADVOCACY

A strong history:

1983- Child and Adolescent Service System program

1986-State Comprehensive Mental Health Services Plan Act

1992- Comprehensive Community Mental Health Servicesfor Children and their Families Program

1996- Mental Health Parity Act

2010- Paul Wellstone and Pete Domenici Mental HealthParity and Addiction Equity Act

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SOLUTIONS: ADVOCACY

Legislators and their staff often unaware ofchildrens mental health issues

A great education opportunity

American Association of Child and Adolescent Psychiatristsprovide specific language and talking points on a variety ofissues

http://www.aacap.org/cs/advocacy

State Level Advocacy is important

CHIP and Medicaid implementation

The Media is another great target

Public also often unaware of mental health issues

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MENTAL HEALTH AND THE ACA

Medicaid and CHIP expansion

133 % of the Federal Poverty Level

Section 5203 of the Affordable Care Act (ACA)

loan repayment program up to $35,000/ year pediatric sub-specialists and providers of mental and

behavioral health services working in underserved areas

up to $50 million for coordinated and co-location ofprimary and specialty care in community-basedmental and behavioral health settings

grant program for School-Based Health Clinics

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BACK TO THE CASE

What we did:

Initiation of Medicaid enrollment process while patient inthe office

Plan for counseling services at Valley Mental Health

Defer any ADHD treatment

Consent obtained to contact the school

Telephone calls to the school nurse and to the childsteacher

Mother enrolled in Partera program

Follow-up in 1 month to check on progress

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RESOURCES

AACAP Committee on Health Care Access and Economics Task Force on MentalHealth. Improving mental Health Services in Primary Care: Reducing Administrativeand Financial Barriers to Access and Collaboration. Pediatrics. 2009; 123; 1248.

Alegria, Margarite, Melissa Vallas, Andres Pumariega. Racial and Ethnic Disparitiesin Pediatric Mental Health. Child Adolescent Clinicians of North America. October2010: 19 (4): 759-774.

Meschan Foy, Jane, James Perrin. Enhancing Pediatric Mental Health Care:

Strategies for Preparing a Community. Pediatrics. 2010; 125;S75. Ptakowski, Kristin Kroeger. Advocating for Children and Adolescents with Mental

Illnesses. Child Adolescent Psychiatic Clin N Am 19 (2010) 131- 138.

Sarvet, Barry, Joseph Gold, Jeff O. Bostic, Bruce Masek, Jefferson Prince. Improvingaccess to Mental Health Care for Children: The Massachusetts Child PsychiatryAccess Project. Pediatrics. 2010; 126-1191.

Supplement to Pediatrics. Enhancing Pediatric mental Health Care: Report for theAmerican Academy of Pediatrics Task Force on Mental Health. Pediatrics. June

2010. Vol 125. Supplement 5. U.S. Department of Health and Human Services. Mental Health: A Report of the

Surgeon General. Rockville, MD: U.S. Department of Health and Human Services,Substance Abuse and Mental Health Services Administration, Center for MentalHealth Services, National Institutes of Health, National Institute of Mental Health,1999