Physicians Seek to Focus Attention, Resources on Children's Mental Health Care
Cover Story -- April 2002
By Ken Ortolon
The future for Texas kids suffering from mental health problems looks lousy.
While physicians report a growing number of children with emotional problems and serious mental illness, children's mental health care seems to be at the bottom of the food chain in the financial resources being put into services. State dollars appropriated for children's mental health care fall far short of meeting the demand for care. Furthermore, physicians say managed care has starved down mental health benefits in private health plans to levels that have driven child psychiatrists out of the field and made obtaining adequate inpatient care for seriously ill children almost impossible.
The resulting lack of mental health facilities and professionals in some parts of the state makes getting services problematic, even if you can afford to pay for them.
As a result, thousands of Texas children and adolescents are going without treatment or, in some extreme cases where desperate parents run out of options, are ending up in the juvenile justice or child protective services systems, further taxing already strained resources.
At the request of mental health advocates such as the Mental Health Association of Texas and the Children's Hospital Association of Texas (CHAT), Lt. Gov. Bill Ratliff directed the Senate Health and Human Services Committee to conduct an interim study on the availability and adequacy of mental health services for children and adolescents. That study is examining services funded through the Texas Department of Mental Health and Mental Retardation (TDMHMR), Medicaid, the Children's Health Insurance Program (CHIP), and private health plans.
Meanwhile, the Texas Medical Association has developed resources to help pediatricians and family practitioners deal with mental health problems. Physicians and mental health advocates also are looking at new approaches to providing care, including school-based mental health services.
The Numbers Game
Texas pediatricians and family physicians say they see a substantial increase in the number and severity of children with mental illnesses.
"We're seeing a huge, huge escalation in mental illness in our children's population," said Waco pediatrician Karen C. Kemper, MD, a member of TMA's Committee on Child and Adolescent Health. "Nobody's quite sure why that is. Everybody has their own personal theories, but that's alarming to us."
According to a report issued in 1999 by then-U.S. Surgeon General David Satcher, MD, PhD, one in five American children experience a behavioral or mental disorder and about 5 percent have extreme impairment from mental or emotional disorders.
TDMHMR estimates there are some 662,000 children and adolescents in Texas with mental health problems, and about 150,000 meet the criteria for serious emotional disturbance and require publicly funded services. However, at a hearing on children's mental health issues in Fort Worth in February, TDMHMR Commissioner Karen Hale told the Senate Health and Human Services Committee that the agency's budget allowed it to serve only about 26 percent of those who qualified, or some 39,000 children, during fiscal year 2001.
State Sen. Eliot Shapleigh (D-El Paso) called that the "biggest issue in mental health" in Texas. "It seems to me we are on the cusp of a civil rights violation for the children of Texas if all we're doing is funding 39,000 of the 662,000 who have some sort of treatable disorder," he said.
Vicki Spriggs, executive director of the Texas Juvenile Probation Commission, told the Senate committee that more than 10,000 children and adolescents on juvenile probation in 2001 had mental health problems. Some, she said, were in the juvenile justice system because their parents were told that was one way to assure that they received mental health services. Sometimes, the parents themselves filed the charges, she added.
Other kids were placed in the custody of the Texas Department of Protective and Regulatory Services (TDPRS). Thomas Chapman, the agency's executive director, told the senators that some desperate parents give up their parental rights to make sure their children get mental health services.
"Many of the parents have exhausted their financial resources trying to obtain services for their children," Mr. Chapman said. "Few families can afford to spend more than $100 a day for residential care for their children. It's just out of the reach of most of our budgets."
The Managed Care Paradigm
If this sounds like a problem only for the poor and the uninsured, it's not. Even if you have health insurance, physicians say getting mental health care for your child can be a daunting task.
Austin psychiatrist Deborah Peel, MD, president of the National Coalition of Mental Health Professionals and Consumers and past president of the Texas Society of Psychiatric Physicians, says managed care has starved down coverage for mental health care almost to nothing.
"Managed care has cut off inpatient psychiatric services, particularly for any mental health specialty units, and that includes children's services," Dr. Peel said. "It's a very desperate situation, unless you're Bill Gates and you can pay out of pocket. In some cases, the only option is to hope your kid commits a crime and goes into the juvenile justice system where he'll get psychiatric services."
Dr. Kemper says even so-called "good" insurance plans provide "dismal" mental health coverage because it is enormously expensive.
"If you're talking about a child who has depression, you can count on treating that child with medication for six months to a year," she said. "And if you want to make a change in that child's life and you want to change the dynamics in that family, that's not something that's going to change overnight, Through counseling, there is hope that you can do that, but that's going to take anywhere from six months to a year or maybe two or three years of counseling on a weekly basis. You can put a pencil to that pretty quickly and figure out how expensive it is."
CHIP offers a fairly generous package of mental health benefits, but physicians say there aren't enough children's mental health professionals in the CHIP network. They worry that the cost of those benefits will swamp the program.
Going It Alone
Meanwhile, primary care physicians say they are on the front lines of the children's mental health care battle with few reinforcements. Dr. Kemper practiced in Abilene for 15 years before moving to Waco. She saw a wide range of mental illnesses there but had no one locally to refer children to or to turn to for support.
"When I was in Abilene, for years and years we didn't have any child psychiatrists who would see children under any circumstance," Dr. Kemper said. "The frustration was having these patients and not having any help for them. I was forced to be a mental health professional when I really didn't have the training in that area to the degree that I needed. I felt like I was way out of my league all the time."
Dr. Kemper is not alone in that feeling. Debra Berndt, director of children's services for TDMHMR, says many rural areas are desperately short of children's mental health professionals. "That's really a problem because we have big areas of the state where there's not a single child psychiatrist in our system."
Dr. Peel says the number of child psychiatrists has always been low, but managed care has decimated the available services. "We used to have facilities where there were psychiatrists, psychologists, nursing staff, psychiatric techs that had been working together in integrated teams for years to deal with seriously ill children," she said. "All of those staffs have been dispersed and destroyed because managed care doesn't pay for any kind of lengthy or complex chronic mental illness."
Getting a Grip
Austin family physician Celia B. Neavel, MD, a member of the TMA Committee on Child and Adolescent Health, says the real frustration for physicians is knowing that kids and their families can be helped and not being able to do so.
"There's so much more that we could be doing that's preventive and working at lower levels before things end up escalating," said Dr. Neavel, who has completed fellowships in adolescent medicine and developmental disorders and sees a substantial number of children with mental disorders in her practice. "Families right now are under so much stress that you really feel for them. The families are just trying to support themselves. Often they don't have time to pick up on the needs that their kids may have."
To help primary care physicians deal with mental health issues that arise in their practices, the committee has developed Integrating Child and Adolescent Mental Health Into Primary Care: A Resource Guide for Physicians.
The resource guide is designed to give primary care physicians tools that they can integrate into their practice to make them more comfortable dealing with mental health issues.
The guide contains tips for prevention and counseling, guidelines for preventive care, tools for early identification and screening, and case studies on common childhood psychiatric disorders. It also includes tips on how primary care physicians can work in their communities to coordinate mental health services among schools, state agencies, the juvenile justice system, and other entities.
Dr. Neavel says schools can be an important partner in the battle against mental illness. "Members of the child and adolescent health committee feel that schools are often a logical place to do a lot more work with kids at a preventive level," she said. "But that requires staffing within the schools."
The Dallas Independent School District is at the forefront of this effort. Jenny Young, MA, who was a manager and policy analyst in the TMA Public Health Department when the resource guide was developed, says Dallas ISD has led the charge in building proven models to address mental health in schools. Its efforts include bringing in a local child psychiatrist weekly to provide psychiatric services for students who need help and are not getting it elsewhere.
Dr. Neavel also works with children in the Manor schools near Austin. She has developed a close relationship with three school district outreach workers that has resulted in a team approach to providing care.
"That model has worked really well. If I'm seeing a kid that I'm worried about, I just pick up the phone and call one of the outreach workers," Dr. Neavel said. "They can do a home visit. They can talk to the family. They can talk to the teachers, be my eyes and ears, and then get back to me on what's going on and where we need to go with the kid."
Get This Parity Started
Meanwhile, mental health advocates are asking the legislature to take action to improve access to children's mental health services. A stakeholders' group including representatives from the mental health association, TMA, and CHAT made recommendations to the Senate Health and Human Services Committee in February.
The group recommended requiring Texas Department of Health (TDH) school-based health clinics to include a mental health component, and restoring some $5.8 million in TDMHMR and $13 million in TDH funding cut from those agencies' budgets on the assumption that CHIP's mental health coverage would pick up the slack. The group also asked for expansion of the Texas Integrated Funding Initiative that allows local communities to coordinate services among multiple agencies to improve care and maximize use of resources.
It also recommended that lawmakers require private insurers to provide mental health coverage for children equal to the coverage for medical illnesses. In fact, children's mental health parity legislation nearly passed in 2001. The House passed House Bill 1491 by Rep. David Farabee (D-Wichita Falls), while the Senate passed companion legislation by Sen. Leticia Van de Putte (D-San Antonio). Unfortunately, the two chambers did not agree on a single version of the legislation.
"This was a top legislative priority of mine because I truly believe that early diagnosis and treatment of mental illness in children will invariably lead to a healthier development and a more promising future for those children of Texas affected by these illnesses," Representative Farabee wrote in a letter urging House Speaker Pete Laney to order an interim study of children's mental health issues.
He said preliminary research shows that early diagnosis and treatment of children's mental illness improves their ability to learn and keeps them out of the juvenile justice system. Adequate mental health coverage also saves taxpayers money by cutting the cost of extended treatment and reduces school failure and dropout rates, he said.
Speaker Laney did direct the House Public Health Committee to conduct a review of access to programs and treatment options for mental illness and substance abuse, but that study is not specific to children's mental health
But getting children's mental health parity is not going to be easy. Health plans and employer groups likely will fight any parity bills filed in the 2003 session of the legislature. In a publication entitled "For the Record -- Voting for Texas," released in October 2001, the Texas Association of Business and Chambers of Commerce (TABCC) rated the pro-business leanings of Texas lawmakers during the 2001 session. In TABCC's rankings, a vote for children's mental health parity was considered a vote against business.
Dr. Peel says the coalition she heads is launching a campaign, "Inform America About Real Mental Health Care," to battle the lack of funding and mental health coverage parity.
"What we're saying is, you ain't going to have it until you have real funding, real benefits, and real parity," she said. "I think part of the problem is families don't know that comprehensive services should be available to protect their children and to keep them safe until they're well enough to return to school or return home."
Too often, she says, families simply accept what the health plans say the level of benefits should be rather than fighting for services.
"The situation is never going to get better unless people demand treatment to full recovery," Dr. Peel said. "You can tell if your child or your adolescent is back to normal, is able to function, and is safe. If not, don't accept an end to service or an end to treatment. Appeal and fight for your child's recovery and fight for his life."
Ken Ortolon can be reached at (800) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.
Help for Primary Care Physicians Is Available
Are you a pediatrician or primary care physician seeing children with serious mental or emotional disturbances? Do you feel like you're in over your head trying to help these children? If so, TMA has some free help for you.
The TMA Committee on Child and Adolescent Health has developed Integrating Child and Adolescent Mental Health Into Primary Care: A Resource Guide for Physicians to help primary care physicians recognize and treat children's mental health issues. The guide includes tips for prevention and counseling, guidelines for preventive care, tools for early identification and screening, and case studies on common childhood psychiatric disorders. It also includes tips on how primary care physicians can work in their communities to coordinate mental health services among schools, state agencies, the juvenile justice system, and other entities.
The free resource guide is available by calling (800) 880-1300, ext. 1396, or (512) 370-1396. It also is available on the TMA Web site at www.texmed.org.
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