Children's Access to Mental Health Care

Much of the conversation about health care reform has focused on the uninsured and on reducing the costs of medical care. Some attention has been paid to access to services, in particular, the effect of declining numbers of primary care physicians available to treat patients. Often left out of the discussion is access to mental health care.

It's been known for some time that the majority of children and adolescents with mental illness are not getting the treatment they need. The Surgeon General reported ten years ago that 1 in 5 children and adolescents have a diagnosable mental illness; 1 in 10 suffer significant impairment in their day-to-day lives; yet, only 20% of those needing treatment in any one year are identified and receive mental health services.

Shape Sorter

A recent study illustrates some of the reasons children don't get treatment. A survey of primary care physicians found that two-thirds report being unable to get outpatient mental health services for their patients. Internists, family practitioners, and pediatricians all reported similar problems in referring patients due to no or inadequate health insurance. But it was the pediatricians who reported the greatest difficulty due to health plan barriers and a shortage of mental health providers.(Cunningham, P. J. (Apr. 14, 2009). "Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care, Health Affairs Web Exclusive, w490–w500.)

In an op-ed in the Boston Globe, pediatrician Claudia Gold describes her problems in referring children she treats for ADHD when they develop symptoms of serious mental illness. Although the standard-of-care requires referral to a specialist, she has difficulty finding child psychiatrists who can take her patients. In the meantime, she remains responsible for their care. She asks:
So how have we gotten to this unfortunate situation where primary care doctors, who are clearly not qualified, are expected and encouraged to treat children with serious mental illness? I believe three main factors are at work. First, the pharmaceutical industry has been successful at promoting the idea that a pill will fix these often complex problems. Second, the insurance industry has made it very difficult for primary care doctors to refer patients for any mental health services. And third, there is a severe shortage of child psychiatrists.
In my area of the country (outside of Washington, D.C.), the shortage is not so much the number of available child psychiatrists but the number who participate in insurance panels. There is no monetary incentive for them to accept insurance. They can easily fill their practices with patients whose parents are willing to pay their fee. Families who must use their insurance may have to wait two to three months for an appointment.

Primary care physicians are put in the unenviable position of being asked to fill the gap in psychiatric services despite their all-too-justified reservations about doing so. Dr. Rob of Musings of a Distractible Mind tells his own story about a child patient needing medication, and I credit his post for raising my awareness of the primary care physician's side of the problem. He also offers a solution--raise low reimbursement rates to encourage more physicians to specialize in psychiatry.
This post was featured in Grand Rounds, Vol. 5, No. 47 - Cost Containment In Healthcare : The Covert Rationing Blog

Kindergarten Attention Problems Affect High School Achievement

A new study published in the June issue of Pediatrics (The Impact of Early Behavior Disturbances on Academic Achievement in High School) provides evidence of the long-term negative impact of attention problems in kindergarten on standardized high-school achievement tests. Six-year-old children who were rated by teachers as having problems paying attention performed more poorly at age seventeen in reading and math when compared to children with internalizing (depression and anxiety) or externalizing (aggression and rule-breaking) problems.

kindergarten is fun

In a press release from the University of California at Davis School of Medicine, the lead author Dr. Joshua Breslau states:
Many children have behavioral problems of the types we examined in this study, but we don’t know which types of problems have the most serious long-term consequences. By identifying attention problems as the most consequential for academic achievement over the long term, this study helps us decide where to put our clinical resources.
One of the co-authors, Dr. Julie Schweitzer, points to the importance of having young children evaluated when they show problems paying attention in school. She suggests that parents start by talking to their child's pediatrician and determine the need for an evaluation by a psychologist.

A careful evaluation of medical and psychological factors related to poor attention is necessary to determine the best interventions. Although attention problems are often caused by attention-deficit hyperactivity disorder (ADHD), other causes include learning disabilities, depression, anxiety, post-traumatic stress disorder (PTSD), poor nutrition, sleep problems, lead poisoning, and a variety of medical illnesses.

For more details on the study's design and results, see Peter West's article at HealthDay.

Ten Common Causes of Child Trauma Due to Violence

I started this post several weeks ago to answer the question "What are the most common causes of child trauma?" It was much harder than I expected. The task of reviewing statistics wasn't just comparing apples to oranges. It was, instead, like comparing the ingredients of a fruit salad. The statistics varied greatly, in part, due to differences in research design:
  • Some studies reported how many children experienced traumatic events in one year while others reported lifetime experience (incidence vs prevalence).
  • Some included only children or adolescents while others asked adults to report on their entire childhood.
  • Most focused on one type of trauma (for example child sexual abuse) rather than a wider range of traumatic experiences.
  • Most weren't large enough or representative enough of the entire nation to draw firm conclusions. (Unfortunately, few researchers are able to obtain the funding needed to conduct large, representative studies.)
  • Those that relied on victim reports to child welfare or law enforcement weren't able to estimate the number of victims who had not reported.
There are several ways to estimate how many children have experienced trauma. One way is to ask about a short period of time (incidence) rather than a person's entire childhood (prevalence). Some advantages of this approach is that it relies less on memory, and it is easier to compare different ages. Otherwise, when asked if an event has ever occurred, more teenagers are likely to report an experience than younger children simply because they've had more years for it to have happened.

A disadvantage is that the results do not reflect the full magnitude of a problem which is often better represented by an estimate of prevalence. For example, a familiar childhood statistic such as "one out of four girls experience sexual victimization before age 18" will be higher than the number of girls victimized in one year. Still, the advantages can outweigh the disadvantages when comparing rates across various traumatic experiences within different age groups, and a one-year snapshot of new cases can be more useful for current policy and service delivery.

My list is limited to child trauma caused by violence because there has been more research done for it than for other traumas (such as disaster or accidental injury). I selected a single study that included a wide range of violence-related victimizations by David Finkelhor and colleagues designed to address many of the issues listed above.
Finkelhor, D., Ormrod, R., Turner, H., & Hamby S. L. (2005). The Victimization of Children and Youth: A Comprehensive, National Survey Child Maltreatment, 10 (1), 5-25 DOI: 10.1177/1077559504271287

Their study included:
  • a large, nationally representative sample of children ages 2 to 17
  • younger children (through interviews with their parents)
  • a comprehensive list of child abuse and other victimization experiences
  • examined the number of victims for each trauma during one year
  • relied on direct reports rather indirect statistics collected by reporting agencies
  • reported how many children experienced multiple traumas
Of the 34 different direct and indirect victimizations included in the study, I've selected the top ten I believe best fit the criteria needed to diagnose PTSD. I converted population rates (number per 1000) to percentages more familiar to most readers. I've also included the definition of each trauma used in the study.

untitled #171. Bullying - 22% - A peer picked on child (for example, by chasing, grabbing hair or clothes, or making child do something he or she did not want to do).

2. Assault with injury - 10%
- Someone hit or attacked child, and child was physically hurt when this happened. (Hurt means child felt pain the next day, or had a bruise, a cut that bled, or a broken bone.) No weapon was used.

3. Assault with a weapon - 8% -
Someone hit or attacked child on purpose with something that would hurt (like a stick, rock, gun, knife or other thing).

4. Exposure to shooting, bombs, riots - 6%

Child was in a place (in real life) where child could see or hear random shootings, terror bombings, or riots.

5. Non-sexual genital assault - 5%
- A peer tried to hurt child's private parts on purpose by hitting or kicking.

6. Robbery by nonsibling- 4%
- A nonsibling (peer or adult) used force to take something away from child that child was carrying or wearing.

7. Physical abuse by caregiver - 4%

An adult in child's life hit, beat, kicked, or physically abused child in any way.

8. Witness domestic violence - 4% -
Child saw one parent get hit (for example, slapped, hit, punched, or beat up) by another parent, or parent's boyfriend or girlfriend.

9. Sexual assault - 3% -
Someone touched child's private parts when unwanted, make child touch their private parts, or forced child to have sex. Or attempted any of these acts.

10. Murder of someone close - 3% -
Someone close to child (for example, family member, friend, or neighbor) was murdered.

There are some surprises here. Bullying was the most common. Significant numbers of children in the United States have been exposed to shootings, bombs, or riots. Many children have had someone close to them murdered though perhaps this shouldn't be surprising given the U.S.'s high murder rate.

In this article, I've focused on the number of children in the United States who experience trauma related to violence. In future articles, I will address other forms of child trauma such as disaster or serious accidents. I will also, from time to time, provide an in-depth look at items in the list including what is known about rates of PTSD and other negative consequences.
This post was featured in Doc Gurley » Grand Rounds, Vol. 5, No. 44: Mystery!