Public Health Feature - October 2008
Tex Med . 2008;104(10):41-45.
By Crystal Conde
Preventing, diagnosing, and treating mental illness in children and adolescents is quickly becoming an everyday part of primary care physicians' practice. Anxiety, attention-deficit/hyperactivity, bipolar, or conduct disorders, depression, and substance abuse are some of the more common mental and behavioral health problems facing young patients.
The U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA) reports mental health problems affect one in five young people at any given time. Given the prevalence of these problems, experts say, Texas must confront a dilemma that a number of organizations and government agencies have thoroughly documented. Too often, children and adolescents fall through the cracks of the system or don't receive adequate care.
Nancy Hitzfelder, MD, a Fort Worth pediatrician specializing in neurodevelopmental disabilities, knows about the dire situation facing young patients with mental health problems in Texas.
An 8-year-old boy came to Dr. Hitzfelder after two health care professionals misdiagnosed him. The young patient revealed in a conversation with Dr. Hitzfelder that he sees things no one else sees and hears voices, mainly those of God and the devil. The frightened boy disclosed that the devil had told him to kill himself.
Dr. Hitzfelder referred the patient to the Excel Center, an affiliate of Millwood Hospital that specializes in treating children and adolescents aged 5 to 18 who have emotional, behavioral, and/or chemical dependency problems. She never received any feedback or follow-up on the boy's condition.
In another case, Dr. Hitzfelder saw a 5-year-old boy who'd been adopted at 6 months and exposed to cocaine before adoption. As an infant, he was irritable and hyperactive. By the time she saw him, he had oppositional defiant disorder. He'd been cutting his mother's hair while she slept, setting the trash and carpet on fire, and exhibiting other destructive behaviors.
He'd already been in an inpatient program and was on high dosages of medications. The boy's parents could not find a physician to manage his medications and couldn't afford behavior management therapy. Dr. Hitzfelder gave them several names of private psychiatrists and adjusted the boy's medications. She says his situation illustrates how difficult it is to find qualified mental health professionals to take a complex case.
Unfortunately, these patients' experiences aren't anomalies. A fragmented mental health system and shortage of child and adolescent psychiatrists make accessing services difficult and add to the patient load primary care physicians carry.
Nationally, Texas is known for failing to devote an appropriate amount of financial resources toward caring for the mentally ill. The National Association of State Mental Health Program Directors Research Institute Inc. ranks Texas 47th in per capita mental health spending.
To make matters worse, the state has a drastic shortage of mental health care professionals. A report by the Hogg Foundation, The Mental Health Workforce in Texas: A Snapshot of the Issues [ PDF ], identifies an inadequate supply of qualified, effectively supported professionals as Texas' biggest mental health workforce woe. Dismal numbers reflect the shortage of child and adolescent psychiatrists in Texas.
In 2007, the Texas Medical Board listed 587 licensed psychiatrists with child, adolescent, or pediatric psychiatry as a primary or secondary specialty. According to the Texas Department of State Health Services (DSHS), 408 of those worked in direct patient care. Of the 254 counties in Texas, only 50 had a child and adolescent psychiatrist. Only 3.2 percent of child and adolescent psychiatrists practiced in rural counties.
The Texas Health Care Policy Council Workforce Partnership, in collaboration with the Texas Medical Association, finds that Texas' 2005 ratio of psychiatrists per 100,000 people had dropped to 5.6, down from 9.8 in 1990. The Texas Health Care Policy Council is an entity of the governor's office that focuses on researching, analyzing, and providing recommendations to improve the quality, safety, efficiency, and effectiveness of the health care system in Texas.
Emilie Becker, MD, a child psychiatrist with DSHS, says the reasons for the child and adolescent psychiatrist shortage in Texas include:
- Lack of exposure to child and adolescent psychiatry training during medical school;
- Minimized financial incentives to complete the two extra years of training needed to practice in the field; and
- New subspecialty programs in geriatrics, forensics, and addictions that may compete for those interested in child and adolescent psychiatry.
A Bigger Burden
The deficit in the mental health labor force increases the burden on primary care physicians, who are seeing more young patients in need of mental health care.
TMA's Committee on Child and Adolescent Health recognized the growing role of primary care physicians in mental health care in 1999 and published Integrating Child and Adolescent Mental Health Into Primary Care: A Resource Guide for Physicians in 2000. A second, updated edition of the guide is now available on the TMA Web site at www.texmed.org/mental. Select Public Health & Science from the menu, and click on Physician Resources to download the PDF.
Austin pediatrician Stephen Barnett, MD, lead author of the guide, says the number of young patients in need of mental health services who walk into primary care physicians' offices has tripled in the past 20 years.
"There's a very inadequate reimbursement system for mental health services, which relates to why we don't have enough mental health workers. As a result, people are going directly to their primary care physicians to get mental health services they would have otherwise sought from a mental health professional," he said.
At TexMed 2007, the TMA House of Delegates adopted a resolution that requires TMA to support legislation to make sure primary care physicians receive reimbursement for behavioral health care appropriately provided in a primary care setting.
To address the need for qualified child and adolescent mental health professionals, the House of Delegates adopted policy at this year's TexMed that recommends TMA promote creating staff positions for physicians with expertise in child and adolescent mental health in all state agencies involved in policymaking regarding children's mental health services.
In addition to developing policy to help meet the mental health care needs of young patients throughout the state, TMA is giving physicians helpful, informative tools. The TMA Committee on Child and Adolescent Health's resource guide provides concise, easy-to-understand mental health information, resources, and principles to help primary care physicians cope with their expanding function in mental health care and identify problems in children and adolescents early on. Highlights of the newer version include:
- A more streamlined discussion of clinical problems that helps physicians efficiently integrate new mental health practices;
- Examples of common problems that can be managed in the primary care office through prevention, screening, and early diagnosis;
- Specific office implementation strategies, including forming an office-based mental health team;
- New community team development and implementation plans;
- Updated reimbursement and insurance information, along with billing and coding recommendations;
- Information on the most common disorders;
- Lists of state and national resources; and
- Tips on how primary care physicians can coordinate mental health services among schools, state agencies, the juvenile justice system, and other entities in their communities.
"This manual shows doctors how to do these things within the time constraints," Dr. Barnett said. "If physicians are only adding on three to five minutes to their health checkups, addressing mental and behavioral health issues becomes easier to manage."
Taking on Mental Health Care
Because primary care physicians follow their young patients' development at regular checkups, they're in a prime position to be able to recognize changes in mental health and behavior. Dr. Barnett says primary care physicians are capable of tending to one-half to two-thirds of the mental health problems they observe and diagnose.
Jason Terk, MD, a Keller pediatrician, says primary care physicians should collaborate with pediatric behavioral and mental health physicians and psychiatrists on questions about the diagnosis or treatment of more complex patients. Dr. Terk is a former member of the TMA Committee on Child and Adolescent Health and a member of the TMA Council on Public Health.
According to the U.S. Surgeon General's "National Action Agenda for Children's Mental Health," in the United States, one in 10 children and adolescents suffer from mental illness severe enough to cause some level of impairment. In any given year, the report estimates, fewer than one in five of these children receive the needed treatment.
Dr. Barnett says about half of the children in the general population with mental and behavioral health problems need specific therapy, and about one-fourth to one-fifth of the children need intensive treatment.
But, Dr. Barnett stipulates, physicians can become familiar with diagnosis and treatment to tackle these less-complicated issues by effectively using a team approach in the office and in the community.
One chapter of the TMA Committee on Child and Adolescent Health resource guide, "What You Can Do in Your Office," outlines discussion topics and screenings physicians can use during office visits to help identify any behavioral or mental health problems. The chapter also highlights guidelines for preventive care, tools for early identification and screening, strategies for developing a health team to improve mental health care in the practice, an overview of allied mental health professionals, reimbursement challenges, and insurance coverage and benefits.
Another chapter covers "Barriers to Prevention and Treatment and Consequences of Untreated Mental Illness." Barriers include decreased access; lack of insurance parity, resources, integrated services, and funding; and stigmatization and stress on families.
A Legislative Budget Board report to the Texas Legislature, Texas State Government Effectiveness and Efficiency: Selected Issues and Recommendations , outlines concern over Texas' fragmented funding and delivery of children's behavioral health services. The report says Texas lacks a central oversight entity to coordinate publicly funded services and a "statewide effort to establish priorities, track spending, assess potential gaps and duplications, and coordinate policies specific to children's behavioral health services." The board recommends developing a system of care through a coordinated, comprehensive, interagency approach.
Dr. Becker says DSHS provides child and adolescent outpatient services through the 38 local mental health authorities (LMHAs) that cover all 254 counties. She says these LMHAs cover a varying number of areas and population needs due to the tremendous size of the state and a lack of resources. The LMHAs also provide cognitive behavior therapy and family support.
"Given the overall lack of child and adolescent psychiatrists proportionate to population, the LMHAs did a great job of having child and adolescent psychiatrists see young patients," she said. "Last year, 75 percent of youths who were seen by an LMHA psychiatrist saw one with training in child and adolescent psychiatry."
Caring for the Community
To help physicians reach children and adolescents beyond their offices, the TMA Committee on Child and Adolescent Health resource guide features a chapter on "What You Can Do in Your Community." Its content includes:
- Promoting physicians as advocates to improve the safety, well-being, and mental health of youth in the community;
- Tips for building a community health team of practitioners, agencies, and programs to better serve patients and their families; and
- Advice for working with schools, the juvenile justice system, state agencies, and state mental health systems; and information on taking advantage of community resources.
Dr. Barnett says that this kind of community approach is known as integrated mental health. Federally funded state initiatives promoting an integrated approach include SAMHSA grants and the Texas Integrated Funding Initiative.
Children's Mental Health in Texas: A State of the State Report, published by the Children's Hospital Association of Texas (CHAT) in 2006, identifies inadequate community-based care as an area of distress in the state's mental health system. CHAT cites decreased funding as the reason for dwindling support of community-based initiatives and recommends an increase in expenditures so children can remain in their communities while undergoing treatment. To view the full report, visit www.childhealthtx.org .
The CHAT report also addresses limitations of public and private insurance. Dr. Becker says accessing quality mental health care in Texas is a challenge regardless of whether families have private health insurance. (See " Child and Adolescent Mental Health Services Procurement in Texas by Insurance Type .")
"Many managed care companies categorize certain mental illnesses as 'behavioral' and will not reimburse mental health professionals to treat patients with these categories of diagnoses. For example, eating disorders fall under this category," she said.
The TMA Committee on Child and Adolescent Health resource guide has information on managed care organizations, Medicaid, the Children's Health Insurance Program, and Social Security for seriously ill children. A chapter on billing and coding provides guidance on preventive and/or acute care services, consultative services, and ICD-9 codes. The appendix features clinical examples from the American Academy of Pediatrics' Developmental Screening/Testing Coding Fact Sheet for Primary Care Pediatricians.
According to Dr. Becker, access to mental health care is no easier or convenient for families who have health insurance. She says many therapists and mental health physicians subcontract separately with insurance companies, making authorization for patient visits difficult at best. Families without health insurance can go to the LMHA or mental health mental retardation center (MHMR) in certain regions of the state. Dr. Becker warns, however, that MHMR clinics' resources and workforce often are stretched to the breaking point, making access to care limited.
The situation is bleak for the most impoverished residents of the state. Children or adolescents seeking residential placement have only one facility available, the Waco Center for Youth with 75 beds. Forty-one beds throughout four of the nine state hospitals are available for children, while adolescents have 198 beds.
Dr. Becker says the state's most severely impaired children and adolescents face a miniscule number of placement options.
"My wish list for children's health care in Texas would include assessing and promoting resiliency," she said. "Most of the mental health efforts expended thus far have focused on getting the unwell well again, not keeping the well from getting ill. We need research into the best way to emotionally strengthen children and their families, to promote wellness, and prevent mental illness."
Crystal Conde can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Attracting Talent in Child and Adolescent Psychiatry
Texas and the whole country face a shortage of child and adolescent psychiatrists. In 1980, the Council on Graduate Medical Education, a committee of the U.S. Department of Health and Human Services, concluded that by 1990, the United States should have more than 30,000 child and adolescent psychiatrists.
Today, the United States has only 7,000, according to the American Academy of Child & Adolescent Psychiatry. The Texas Medical Board reported 587 licensed psychiatrists with child, adolescent, or pediatric psychiatry as a primary or secondary specialty last year.
Emilie Becker, MD, a child psychiatrist with the Texas Department of State Health Services, lists the following ways Texas can attract and retain more of these health professionals:
- Increase recruitment for mental health professionals. High school career counselors could promote these careers as options. In college, and particularly in medical schools, further outreach could improve recruitment of those interested in children and mental health.
- The state could increase funding for the number of child and adolescent psychiatrists trained each year. There now are more approved training spots than funding for them.
- Waive the debt faced by graduating children's mental health professionals through loan forgiveness programs.
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