ACCESS TO CHILD MENTAL HEALTH SERVICES

ADVOCACY MORNING REPORT JESSICA MILLER DECEMBER 7, 2012

THE CASE:
6 y/o boy brought in for behavior issues Started kindergarten this year, mother has been contacted frequently by school for concerns about the patients behavior hitting other children in the classroom often wandering around the classroom and will not listen to teacher

THE CASE:
At home: Spanish is spoken in the home, and most instruction at school is in English Parents separated 2 years ago patient began hitting sister at home soon after father left

THE CASE:
PMH: Term birth, no complications surrounding pregnancy or birth, no past hospitalizations Medications: none PSH: none Social: Lives with mother and older sister age 8. Mother speaks Spanish only. Father has visitation 2 days per week. Entire family uninsured, mother says she started a Medicaid application for the patient, but hasnt heard back

THE CASE:
Physical Exam: T: 36.7 Wt: 20.1 kg GEN: crawling over chairs, messing with lamp in corner HEAD: normocephalic, atraumatic EYES: EOMI, PERRL THROAT: OP pink, moist, uvula midline, tonsils normal appearing NECK: supple, FROM, no masses or lesions CHEST: CTAB CV: RRR, no murmurs ADB: soft, non-distended NEURO: grossly normal Vanderbilt screen completed at last clinic visit and is highly positive by both mother and teacher across inattentive, hyperactive, anxiety/depression areas

THE QUESTION:
WHA T MENTA L HEA LTH RESOURCES A RE A VAI LABLE TO THI S FA MI LY?

SCOPE OF THE ISSUE

Almost 1/5 children in the US suffers from a severe mental health disorder at some point in life Only 20-25% of affected children receive treatment (Mental Health- A Report of the Surgeon General, 1999)

SCOPE OF THE ISSUE

From CDC NHANES

WHY DOES THIS ISSUE MATTER?

Without intervention many child mental health disorders:
continue into adulthood are associated with higher rates of:
poverty school failure poor employment higher utilization of healthcare resources poor social mobility substance abuse

WHAT ARE THE BARRIERS TO CARE?

Systems Barriers Patient Perceptions of:
Structural Barriers Mental Health Disorders Mental Health System

Socioeconomic and Racial Disparities

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 school providers

CHILD/ ADOLESCENT PSYCHIATRY PROVIDER SHORTAGE

7418 nationally (2009)

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

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 and in the community

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

SOCIOECONOMIC AND RACIAL DISPARITIES

Rates of maternal depression in racial minorities may be as high as 30-40% Higher rates of mental disturbance in the juvenile justice system and child welfare system
These systems 50-70% minority children

Lower rates of psychotherapy and psychotropic medication use

WHAT CAN PEDIATRICIANS DO ABOUT ALL THIS?

In the clinic In the community

In the legislature

SOLUTIONS: THE PRIMARY CARE SETTING

AAP task force on mental health has emphasized the importance of the primary care pediatrician in mental health care
Important role given child psych shortage

SOLUTIONS: THE PRIMARY CARE SETTING

Add questions about mental health service use, mental health disorders to new patient visits Incorporate discussions about behavior and mood into well child visits Be aware of high risk populations:
Foster care Parents in military/ national guard LGBT adolescents Significant psychosocial stressors

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 common mental health disorders
ADHD, Depression, Anxiety, Substance abuse

Seek feedback about community mental health resources from families Ask family to sign consent to share treatment information at time of mental health referral

SOLUTIONS: IN THE COMMUNITY

Apply a population perspective to understand mental 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 the community

Enhance communication between medical, mental health and school resources

Each of these have the tendency to operate separately

HOW TO FIND LOCAL RESOURCES

The Mental Health Binder
Agencies Services offered Age range Insurance accepted Spanish or not?

Parteras at South Main Clinic

A FEW LOCAL RESOURCES

Valley Mental Health
www.vmh.com, 888-949-4864 Inpatient/Outpatient mental health services Medicaid
www.fourthstreetclinic.org/servi ces/programs outpatient Uninsured/homeless www.slcoyouth.org, 385-4684500 Short term free counseling, youth and parent groups www.highlandridgehospital.co m 1800-821-HELP Medicaid Inpatient services www.tccslc.org, 801-582-5534 Children <7yo Therapeutic Preschool Trauma Treatment

Highland Ridge Hospital

Fourth Street Clinic

Polizzi Clinic

The Childrens Center

http://polizziclinic.org, 801-4490752 Uninsured New intake 3rd Sat. each month

SLC Division of Youth Services

SOLUTIONS: IN THE COMMUNITY

Grant helps Childrens Center expand work with kids with post-traumatic stress Salt Lake Tribune, November 24, 2012 what looks like ADHD may really be a childs reaction to experiencing trauma $1.6 million over four years Treatment of 400 additional children Focus on refugee, military, foster care families

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 Services for Children and their Families Program 1996- Mental Health Parity Act 2010- Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act

SOLUTIONS: ADVOCACY
Legislators and their staff often unaware of childrens mental health issues
A great education opportunity American Association of Child and Adolescent Psychiatrists provide specific language and talking points on a variety of issues 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

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 of primary and specialty care in community-based mental and behavioral health settings grant program for School-Based Health Clinics

BACK TO THE CASE

What we did:
Initiation of Medicaid enrollment process while patient in the 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 childs teacher Mother enrolled in Partera program Follow-up in 1 month to check on progress

SUMMARY: WHAT YOU CAN DO

Ask about mental health disorders in WCC Initiate treatment for common mental health disorders Know your local resources Where you practice, get to know your community partners Consider legislative advocacy

RESOURCES
AACAP Committee on Health Care Access and Economics Task Force on Mental Health. Improving mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration. Pediatrics. 2009; 123; 1248. Alegria, Margarite, Melissa Vallas, Andres Pumariega. Racial and Ethnic Disparities in Pediatric Mental Health. Child Adolescent Clinicians of North America. October 2010: 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. Improving access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project. Pediatrics. 2010; 126-1191. Supplement to Pediatrics. Enhancing Pediatric mental Health Care: Report for the American 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 Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999