When discussing the state of mental health care for young people in the United States, Reginald E. Bannerman, MSN, MBA, RN, NE-BC, director of Nursing, Psychiatry, at Children's National Medical Center in Washington, DC, is unequivocal: “We are quick to treat diseases like diabetes, but mental health doesn't get the same attention. We have to accept the fact that mental health is a children's health issue.” Mental health and medical problems aren't mutually exclusive, he insists. “We have to look at the whole picture.”
It's estimated that about 4 million children in the United States are affected by mental health problems, yet only about one in five may actually receive care, according to a 2006 report from the National Resource Center for Family-Centered Practice and Permanency Planning at the Hunter College School of Social Work in New York City. More recent data, from the Substance Abuse and Mental Health Services Administration (SAMHSA), indicate that more than half of children between the ages of eight and 15 who have a mental health disorder have received treatment. Other data from recent studies suggest that in the vicinity of 20% of children and adolescents are experiencing serious issues in psychosocial functioning at any given time, and of that group, 5% to 8% have problems serious enough to be considered a mental illness. SAMHSA data from 2001 through 2004 further show that, among eight-to-15-year-olds, the prevalence of diagnosable mental disorders with severe impairment was 11.3%.
According to Bannerman, the solution is in part a political one. “President Obama and Congress should call for a task force to focus on mental health issues,” he says. “And action needs to be taken. We can't just keep talking about it.”
In the wake of recent tragedies involving firearms, particularly the shooting in Newtown, Connecticut, many in the national spotlight have renewed calls for greater attention to mental health in children. President Obama has in fact called for expanded mental health services as a complement to his proposed changes in gun laws. The administration's stance hasn't softened despite a setback in the Senate in April, and its initiatives are aimed at recognizing and treating children, teens, and young adults with mental health problems. They include a recommendation that $150 million be allocated to schools to hire professionals such as psychologists, social workers, and counselors. Another $40 million would go toward helping school districts establish referral systems to ensure that students with mental health problems have access to care. The president also directed Secretary of Education Arne Duncan and Secretary of Health and Human Services Kathleen Sebelius to begin a national dialogue on mental health issues.
If implemented, the initiatives could go a long way toward improving mental health services in this population. As with adults, mental health in children and teens doesn't receive the same attention other health conditions do. Insurance coverage for mental health conditions is often poor, access to resources is limited for many, and too often the coordination of care among the various agencies in health care, education, mental health, addiction, disability, child welfare, and law enforcement is lacking.
IMPROVING ACCESS TO CARE
As with many other health conditions, mental health problems and inadequate access to care disproportionately affect certain segments of the population. As many as 80% of those who enter into foster care suffer from serious mental health problems, but fewer than a quarter of children in the foster care system receive mental health services. Children living in poverty or in rural areas and those who are members of minority groups tend to be more neglected.
Schools are the most common point of entry into mental health services, and more than 80% provide some type of mental health assessment, counseling, referral services, or crisis intervention. However, many children are unable to receive the care they need, primarily because of financial constraints on their families and inadequate school-based mental health resources.
Early screening is important, Bannerman says, especially if a caregiver has noticed behaviors that are unusual or a sudden change in behavior. All too often, a parent or caregiver may identify a problem but doesn't have the resources to help the child, he says. And some parents may not want their children to be screened.
“We can have that debate [over whether children should be screened],” he says. “But if a problem is detected, then we need to be able to provide care. If we catch the behavior but can't move to the next level, then what? We need adequate health care access.”
WILL MEDICAID EXPANSION HELP?
Implicit in the expansion of Medicaid services under the Patient Protection and Affordable Care Act (ACA) are improvements in mental health services. Because Medicaid includes mental health benefits, states that opt in can, conceivably, make mental health coverage available to thousands who may be lacking it now.
“We're coming from the perspective that the Medicaid expansion and the implementation of the ACA state health care exchanges will significantly benefit uninsured people—including kids—with behavioral health conditions,” says Joel E. Miller, senior director of policy and health care reform at the National Association of State Mental Health Program Directors.
Between 2014 and 2019, Medicaid expansion will provide health insurance coverage to 17 million people with incomes less than 138% of the federal poverty level who were previously uninsured, according to Miller. “About 40% of this group—or 6.6 million individuals—with serious or moderate mental illnesses who are currently uninsured will obtain health insurance through the Medicaid expansion.”
So far 25 states and the District of Columbia have committed to participating in Medicaid expansion; 14 states have rejected it, and others are still undecided.
In addition, Miller notes, 6.8 million uninsured people with a mental illness should also gain health coverage through the implementation of state health insurance exchanges formed under the ACA, out of the 18 to 25 million people projected to be newly insured through the exchanges between 2014 and 2019.
THE QUALITY OF MERCY…
Another concern has been measuring the quality of the mental health care that children do receive. “We have [some] quality measures,” says Bonnie Zima, MD, professor in residence and associate director of the UCLA Center for Health Services and Society, but historically they've been used more for accreditation. Under health care reform, though, there is pressure to apply such metrics to publically funded health care.
The development of new child mental health quality measures poses methodology challenges, says Zima. “If we mandate publically funded health care,” she says, we need to know that it adheres to accepted standards. The question then becomes determining which standards are meaningful, she says, adding, “And how do we define meaningful?”
Zima says that nurses must be at the table in determining such measures. Nurses can help to lead collaborative teams. “It's an important niche for nursing,” she says.
Complicating the issue of providing mental health services to children, says Zima, is the fact that a provider may want one thing and parents want something else. There is a need for a new research paradigm, she says, and nurses must help to create it.
Nurses in general need to be at the forefront of planning, adds Bannerman. “This is true especially in primary care and pediatrics, where they see the patient and spend time with the family.”
“The time for action is now,” insists Bannerman. “If we believe that this is the greatest country in the world and we have the best health care system, we have a higher calling to do what is best for future generations, and we must rise to the occasion.”—Roxanne Nelson, BSN, RN