Welcome to the CATCH Services working group blog. This is where those of us interested in transforming children’s mental health across the country can share notes, ideas, co-conspire for change, and keep the ball rolling.
What is CATCH? Collaborative Approaches To Children’s Health has been an idea in the hearts and minds of many of us for a long time. But more recently, an amazing group of revolutionaries, activists, inspired thinkers, and people who care, formed around the purpose of transforming the child health/mental health care system across the US. Those of us participating in CATCH have come to the sad but firm conclusion that our current mental health system for children is broken and cannot be fixed by small, iterative changes in the status quo. Why broken? Because most children with mental health needs cannot get care, given the way that our health care services are currently organized, financed, and reimbursed, and the incorrect values underpinning our current system. Current system values are to minimize costs, but with no accountability for quality, outcomes, or scientific credibility for the services delivered. The other value, an unintended consequence, is that only well-to-do folks who can pay for care out-0f-pocket can get quality care. But even that expensive care is haphazard and subject to chance, as it depends upon the consumer knowing what quality care is and where to find it.
If you are of similar mind, and want to contribute to this dialogue, have at it. We’ll need all the help we can get.
Peter S. Jensen, MD, President & CEO, The REACH Institute (REsource for Advancing Children’s Health).
December 7, 2008 at 4:54 pm |
Let’s get this project started!
December 7, 2008 at 5:03 pm |
I will send this blog listing to others from the gathering and include the people who were unable to attend our first meeting.
December 8, 2008 at 3:06 am |
I am looking forward to a dialogue. I very much enjoyed meeting everyone.
December 8, 2008 at 9:47 pm |
Peter,
Enjoyed speaking to you about children’s mental health needs. Welcome to Mayo.
Mike
December 10, 2008 at 7:54 pm |
Looks like studies agree with you, Peter:
“New research by the National Center for Children in Poverty at Columbia University reveals that state by state policies continue to hinder children’s mental health delivery 25 years after the strong recommendation of a federal plan to address the issue. The complete findings of this research debuted at the 24th annual Rosalynn Carter Symposium on Mental Health Policy on Nov. 20-21, 2008, at The Carter Center in Atlanta.”
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Press release 11/12/08
The Carter Center
December 10, 2008 at 8:15 pm |
The blog has been sent out to most people present & is now going to the folks who wanted to attend yet could not. There are a half dozen more persons to be listed.
December 14, 2008 at 3:37 am |
As a mom of four children and a friend to many moms, this is a very interesting subject to me. I don’t know if my children will ever have mental health issues, but I think it’s wise to decide now how I will handle it if they do and know where and how to find quality care.
As a child, I was sent to a couple psychiatrists due to chronic headaches of unknown origin and it was an intimidating experience. I felt judged, looked down upon, and with one it was as if she was suspicious something sinister was happening in my family, which I resented.
During one of my sessions, I felt like I was being stared at, scrutinized, and then she asked me about the mark on my arm. I said, “That’s a rugburn.” She asked, “How did you get it?” “My brother.” “How did he do that? Does he hurt you often?” I felt defensive at once and didn’t feel I could trust her. The incident was just a normal case of sibling rivalry and I felt she was trying to paint him as a bad person. I had teased him mercilessly, knew it, and it was no surprise when he pulled me off the couch, onto the carpet, and caused a rugburn. When she asked me how school was that day, I said, “Fine.” In a rather accusatory tone she said, “FINE? Just FINE?” I said, “I’m in 7th grade. School doesn’t get any better than fine.”
So my first suggestion would be more training on helping a child feel comfortable and safe. This is a necessity for the parents too. As soon as I told my mom about my discomfort in that office, she thought the line of questioning was ridiculous and didn’t bring me back.
I would find it difficult to visit a mental health professional as an adult and perhaps even more difficult to put my children through the same experience, although I know there are more talented doctors out there.
I am 33 years old and when I was in school, I never heard a word about mental health until my Psychology 101 class in high school and that was just for the purpose of learning about disorders and the history of psychiatry. What we learned was never applied to ourselves and felt like, “These are disorders that other people have” when in reality, I bet many people in the class had suffered or were suffering from depression, anxiety, ADD, etc.
We learned about many subjects beyond academics thoughout my schooling (fire safety, resisting peer pressure, the evils of cliques, and others), but nothing related to mental health. I would be surprised if this hasn’t changed already, but if it hasn’t, I think it would be great if it were addressed in the schools and support groups formed to help everyone see that they are not alone, both parents and students. Parents often turn to each other for doctor referrals, but there is still this sense of shame when it comes to mental health. If we could eradicate the stigma associated with mental illness, I think more parents would be asking, “Hey, do you know a really good psychiatrist?”
As a parent, I think it would be incredibly helpful to know what behaviors are normal in children and when to be concerned. Education on warning signs would be great too. Also, to know what to expect when seeking help. Two friends have avoided having their children evaluated for years – one because she didn’t want her son being labled and the other because she had the impression medication would be the only solution given.
At this point I have nothing to suggest as to affordable mental care for all children who need it. Affordable health care in general is such a dilemma, but I hope someone will come up with a creative solution. I know if my kids needed it right now, I wouldn’t be able to afford it.
December 14, 2008 at 7:42 am |
Our Greater Cincinnati Pediatric Mental Health Task Force appreciates the efforts by this group and particularly Dr Jensen in pushing this effort forward. The state of Ohio is in the process of trying to centralize services in the area of child mental health issues . One of the concepts is to develop regional networks similar to the Massachusetts plan but it is an uphill struggle due to the politics and the economy.
December 14, 2008 at 12:38 pm |
This blog is admittedly quite provocative, as it concerns the simple premise that our child mental health system as it currently exists is broken, and cannot serve the needs of the nation’s children without some drastic reorganizational changes.
Why have many of concluded that the system can’t be fixed, as is? We begin from the simple observation that there are 7000 child psychiatrists, of which there are about 4000 FTEs actively working in child mental health, and perhaps a slightly smaller number (~3000, but no one knows for sure) of trained and certified clinicians with substantial experience with child mental health problems (developmental-behavioral pediatricians, child psychologists, nurse-practitioners, social workers, etc.
Given 7000 specialists trained in child mental health, and with 10% of the nation’s 70 million children having clinically significant emotional/behavioral disorders at any point in time, each specialist would have 1000 children to see in a given year. Given a 40 hour work week, and 50 work weeks per specialist (2000 clinical hours/year), if parity now allows us to help all children in need, and stigma and other access barriers are addressed, each child/youth with clinically significant problems could see a doctoral level mental health specialist for 2 hours a year. If you count charting and billing, etc., the time drops to 1.5 hours.
Then, to top it off, many of my colleagues find themselves only seeing those persons who can pay out of pocket, as the reimbursements systems are too onerous, very paperwork intense, or in some cases, it even costs more to keep the office running that what is reimbursed. To my mind, a sliding scale solution is need, where costs of care are spread across income categories, but with the goal that all persons be able to be seen and get high quality care, regardless of income level…
Without drastically reorganizing how we deliver mental health services, i.e. how we use our child-mental-health-trained specialists, as well as our more generally trained social workers, nurses, and primary care clinicians, most children with significant mental health needs will never get their clinical needs met.
To weigh in on related issues, go to http://thereachinstitute.wordpress.com, read the post, and add your thoughts.
pj
December 14, 2008 at 3:43 pm |
The personpower lament seems to assume providing services in the same old way, ignores the cadre of psychiatric social workers and school psychologists and counsellors, and does not consider multiplier technologies or the advantage of solving one problem with another. E.g., 2 hours per child average may be enough for many cases if it happens to be 8 hours of group therapy or multifamily group therapy in a group of 8 plus 2 half-hour consultations on med management by the pediatrician or specialized certified pediatric nurse practitioner. Group parent training for 12 hours in a 6-family group may be all that is needed for younger children.
More important, however, is the possibility of two problems solving each other. Although we appear to have a shortage of doctoral child MH professionals, we also have a problem with drifting and lack of purpose with many adolescents and young adults, and a growing unemployment problem. To put some meaning and purpse in their life, they could be trained as volunteers or even paid cheap paraprofessionals in specific interventions. There is a model for this in many ABA programs for autism, and to some extent in the STPs. High school juniors and seniors could earn social studies credits for volunteering in specific labor-intensive interventions under professional supervision. This could be a good activity for college work-study students. Further, those who are laid off or fired and collecting unemployment could be expected to devote 20 hr. a week to such work and 20 hr. to job hunting. The experience and favorable reference could help qualify them for a job.
Finally, we need to think about primary prevention at least as much as treatment. There is increasing evidence of the importance of early nutrition and affective/cognitive/verbal stimulation for brain development. Early prevention might reduce the number later needing doctoral professional attention to a manageable number. Although the best time for prevention is gestational through preschool, even early school age is not too late, and the educational establishment has to be involved in any solution.
One additional thought: the solution does not necessarily have to cost more, or even as much as the current system. I heard an interesting report yesterday about the fact that Cubans live longer than Americans despite a much less expensive health care system: someone figured out that if you correct for the health benefits of poverty –how many miles they walk a day because they cannot afford to ride, the fact that they eat a lot of whole grains because they cannot afford processed food, the fact that they generally don’t overconsume and get obese, etc.– there is no difference in longevity. In other words, they live longer because they are poor. So more expensive is not necessarily better. Doctoral level professionals are more expensive –do we know whether they are better?
December 14, 2008 at 7:28 pm |
An effective way to use child psychiatrists is to have them be consultants to those in primary care and also to therapists. If we organized primary care for children around either their family physician or pediatriican and then estabilshed a team of therapists, psychologists and child psychiatrists as a consulting network, ot would be possible to provide both preventive and direct care in an organized way to families. If the insurance company funding the family required that the family have a primary care physician, then the reimbursement for these serivces could also be organized in a way to encourage effective utilization of tlaents abilities and financial resources.
In this model the direct care provided by child psychiatrists would be as consulant unless the complexiity of the situation required direct therapy or evaluation services.
in this model also the counselling services might be delivered in himes as well as in offices,or in community centers in cases where intenisve parent training or other group inteventions were needed.
Telepsyhciatry could also be employed using this model.
An effective way to develop this model would be to hire child psychiatrists as employees with appropriate salaraies, and satisfactory benefits, so that they can be entirely devoted to clinical service . This might appeal to those who do not like the business of running and office and makng it profitable . There are probably countless hours of professional time going into the business of psychiatric practice every day which , if removed, could be channelled provide may more hours of child psychiatry service than are now available.
December 14, 2008 at 8:42 pm |
Dear Colleagues, I am honored to join this discussion, and learned a lot from the comments posted above: from the point of view of the scholars, academicians, clinicians, and also parents (asking for information of normal child development). I am looking forward to working with all kinds of professionals from various settings and areas in the country. I appreciate the “top-down”, “systemic” point of view (looking from the perspective of how to provide the best, effective, ethical, empirically-based service to the very nigh number of children in our country in need for mental health and psychiatric services), and also the need for learning from individuals (“down-up”) of their strongest need for help, i.e., learning from parents, from patients, and from other sources (such as schools, families, pediatricians, and even law-enforcement agencies). Finally, do the participants in this discussion agree that prevention and education constitute a third (and maybe the most effective measure in the long run) element to plan and to implement in working in improving mental health of our children in our country? Involving pediatricians in screening for mental health disorders, and providing education for the general public about “normal child development” as well as”early signs of mental health disorders” has been the focus of some of the discussants (such as the role of the Reach Institute). Thank you, Vera Joffe, Ph.D.
December 14, 2008 at 11:31 pm |
“If you are of similar mind, and want to contribute to this dialogue, have at it. We’ll need all the help we can get.”
I am the mother of a child whose diagnosis from approximately 12 years ago has changed at least four times, with modes of treatment staying the same and medications that were inadequate. Nothing different was done as he sunk deeply into the devastating illness. I am so convinced that we need to change as much as we can with this system and that his life, as well as others depends on it. I am ready to help.
December 15, 2008 at 8:41 am |
Kim Masters would be pleased to know that we already have such a consultative model in the state of Massachusetts. The project is called the Massachusetts Child Pyschiatry Access Project ( MCPAP).
Just as Kim described -we do have mental health teams ( child psychiatrists, licensed therapists, and care coordinators) to assist primary care clinicians in six regions across the state of MA. Our services are insurance blind, and right now we are funded by the state of Massachusetts.
We have received telephone calls and emails from interested parties all over the US who want to duplicate what we have done here in Massachusetts.
So far, we have 350 primary care practices (roughly 97% of the state) enrolled with MCPAP. This is a highly utilized service. For the last few months, we have been handling over 1600 encounters per month.
If you want to learn more about MCPAP, please visit our blog at http://www.mcpap.com. If any one wishes to speak to someone directly about MCPAP, please contact the MCPAP Project Manager, Martha Page at martha.page@valueoptions.com.
December 15, 2008 at 12:53 pm |
Dr. Arnolds comments ring “true” – recognizing the resources and expertise a variety of disciplines bring to the task…there’s no mention of psychiatric nurse practitioners and clinical specialists in this blog…yet…but we’re out here, working, … consider the potential for impacting care when the conversation is inclusive…thank you for the invitation.
December 15, 2008 at 2:22 pm |
Peter: I wonder if the recent public outrage about the child “abandonments” in Nebraska might help stimulate public discourse and action. Most of the kids had mental health problems and had tried to use state services previously (Time had a good article on this).
December 15, 2008 at 3:37 pm |
Drs. Jensen and Arnold,
Your numbers are slightly disingenuous. While it is true that there may be only 4000 or so board-eligible or -certified child psychiatrists, there are far many more practitioners out there providing mental health care to children than those numbers suggest. While I do not have the exact figures (but I am sure you could provide useful estimates), most children in the community receiving psychotropic medications are being treated by pediatricians, neurologists, and general psychiatrists, not by us “specialists” who have more years of training and therefore cost more to use.
This is partly an economic problem, and partly a political one. We as a field have chosen to restrict who can call themselves a child psychiatrist by requiring that they have five or six years of post-graduate training in order to be a “child psychiatrist.” Few medical school graduates make that economic decision, to forego practice income for the extra years, when it will not increase their income as substantially as it may cost them in foregone income early in life. This is what economists refer to as “time preference” in deciding whether to forgo present benefits or income, or to enjoy the products of our labor today. We must make the choice to save for the future or invest today ( in the time spent on education and the lower income today of remaining a trainee) to reap greater rewards in the future. If those rewards are not great relative to the foregone present income, there is insufficient incentive to draw new practitioners into the subspecialty field.
Again, using simple economic analysis, we can point out that the supply of board-eligible child psychiatrists will be driven by the actual demand of the marketplace. By making ourselves too exclusive, we have priced ourselves out of the market. If there are “too few” child psychiatrists, it is because society as a whole does not value our services sufficiently to pay the wages that would convince medical students to pursue the extra training to become a child psychiatrist.
We can only blame ourselves as a field for not providing services that consumers value and demand at higher rates. As Sarah has pointed out above, this is a reality. When families get so turned off by the foolishness and arrogance of doctors who ask intrusive and insensitive questions and take an authoritarian approach to providing health care, and when we do not provide the quick relief they want, but instead insist that they must suffer through endless hours of talking to us as the expert in order to “get well,” then they will turn to other channels to get help. If pediatricians and neurologists don’t approach the problem with questions about whether you want to sleep with your mother, and view the emotional and mental distress as a medical problem that can be solved quickly, rather than making the patient feel judged and misunderstood, then they will get the business and we will not. Sarah, Tami and their friends have a right to be indignant about our self-righteousness and the difference in our approach compared to other doctors.
Why are psychiatrists so different in their approach to the patient compared to other doctors? Well, here is where politics may enter into the discussion. As a field, psychiatry has always had an often unspoken collusion with the state and authority as one of the skeletons in its closet. Until the mid twentieth century, most psychiatric care was provided through state institutions that had justifiably terrible reputations, since they were closer to prisons in the way they managed patients than to private hospitals. Even today, we continue to be the only field in medicine that routinely treats patients against their will. This is a part of our collective culture and consciousness as psychiatrists that we must change if we wish the world to value us in the same way they do other medical specialists. As long as we continue to act as unwitting agents for the state, without understanding how that makes our patients suspicious of our motives and behavior, as Sarah pointed out above, then we will continue to drive customers away.
Kim points out that we need to be simply part of medical team, a consultant that assists the primary physician, rather than view ourselves as the sole provider of psychiatric wisdom and mental health, as so often occurs in the real world. This is another way our model has to change. We must make ourselves more useful to non-psychiatric practitioners as consultants, with expertise for more complicated cases that they cannot manage alone. Yet our typical approach is to insist that we have full responsibility for all of the mental health needs of the child, rather than a limited role. And the reality of our field is that the knowledge base about what constitutes mental health and illness in children, and how to treat it, still has too many gaping holes in it. Until we can show that what we do is as valuable to society as what cardiologists and neurologists do, then we will continue to be undervalued.
My arguments are not intended to devalue psychiatry, psychotherapy, or the immense progress in understanding mental function and dysfunction that we have made in the past century. But I do think we should challenge ourselves to change what we do, if we wish to be more valued in the modern world.
How’s that for some provocative ideas?
E. Steven Dummit, III, MD
Director of Psychiatry for the Westchester Division
Jewish Board of Family and Children’s Services, Inc.
J. M. Goldsmith Center for Adolescent Treatment
Hawthorne, NY 10594
December 15, 2008 at 6:10 pm |
Submitted for the writer via email, by The REACH Institute
Hi Peter;
Great idea for the blogs. I’m not sure parents with ADHD, with kids with ADHD will have the time to visit blogs regularly, however. That said, I just want to put in my two cents regarding the dearth of child psychiatrists. About 2 years ago, we had to leave our child psychiatrist, who we had been with since my kids began meds around age 5. He no longer took insurance. That is a huge problem. He was billing my insurance company for 45 minute visits for 2 kids, under what was then a medication management CPT code, but seeing us (2 kids and parent) in one room simultaneously for a total of 30 minutes. He charged $185 per kid, and we had to come every 30 days or not get our stimulants refilled. Who can afford that??? So we switched to a developmental pediatrician in our plan. Now, we go every 3 months and only pay a copayment. The down side is that on the whole, developmental pediatricians are not that savy regarding complex medication management, and we really need a psychopharmacologist. But, we are forgoing that option due to the fact that NO psychiatrists take insurance. And, just try to find a psychopharmacologist. HA! Therefore, even kids whose parents are educated and involved, and who know the mental health system, are under-served. Just my 2 cents.
Warm regards,
Lisa LaVardera-Guidice
CHADD Chapter Coordinator
Certified Parent to Parent Trainer
Special Education Attorney
December 16, 2008 at 9:42 am |
I absolutely agree with the premise that the Children’s MH system is broken and needs significant change to meet the needs of American children. I also completely agree with the shortage of child psychiatrists (especially in Texas) and licensed psychologists. However, I take exception to the idea that these are the only professionals with the education/experience to treat these children in need. I’m a Licensed Clinical Social Worker in Texas with over 20 years experience treating children and families with mental health challenges. I’ve taught graduate courses at the University of Texas, Austin, and have lectured myriad times to graduate classes and at regional, state, national and international conferences on child and family mental health issues. There is a large corp of Clinical Social Workers, Licensed Professional Counselors and Marriage and Family Therapists available to treat children with emotional disturbances and mental illness, and I dare say some of them are more capable of facilitating postive change than some psychiatrists and psychologists. So, while addressing the shortage of professionals in those two important disciplines, please don’t insult the other professional disciplines which have clinicians in the trenches every day working with the most challenging children in our society, by inferring that only psychiatrists and psychologists can treat the targeted population in need.
December 18, 2008 at 2:22 am |
Let me be clear in response to Michael. For severe problems like cancer, we need cancer specialists. For child mental health, every case is not like cancer, but some are: for cases of severe aggression, bipolar, OCD, major depression, schizophrenia, autism, comorbidity, you want the entire range of specialists there. In the case of cancer, you need an oncologist, but you also need much more: radiologists, radiation therapists, nurses, occupational therapists, phlebotomists. Severe cases of childhood mental illness probably constitute, as best we know, 4 million children. Most of the standard of care suggests that they need multidiscplinary teams of social workers, psychologists, child psychiatrists, NPs, special educators, and pediatricians, to render truly expert, high quality care.
Across these disciplines, there are some overlapping roles here, but unique roles as well. I would argue that in those severe cases, a minimum of 3-4 regularly communicating professionals will be required, one of which will like need to be a child psychiatrist, or someone specially trained to work with complex cases that require medications, therapy, physical assessment/evaluation, social work, and probably education.
If we treated cancer the way we do severe psychiatric problems, the child would go to see just one of the six or seven specialists needed, depending on whatever door the family happened to walk in, and that clinician would not talk with the other 6 specialists, all of whom would be in separate offices…there would be no team.
So, go back to my initial point; Assume 7000 persons especially trained in these complex cases, they have 2000 hours/year available. 2000 x 7000 = 14 million hours to treat 4 million kids, gives each kid 3.5 hours of that particular kind of specialist per year. The average service episode for child mental health across the US is about 10-12 hours per year.
Doing the math, this means that if you believe that severe cases need multidiscplinary care, e.g., SW, psychology, psychiatry, peds, nursing, UNLESS many of us are willing reorganize how we do care, i.e., get out of our solo office practices and re-form ourselves into multidisciplinary teams to bring all of our skills together, we will never be able to solve the current MH crisis.
Speaking about my own discipline, if I spend all my time seeing cases all by myself, doing the therapy, medication, school consultation, etc., in effect spending that 10-12 hours with a family all by myself, there will never be enough child psychiatrists to go around. But if I align myself with a team, I can spend 2-3 hours with every child, out of the 10-12 hours each family gets on average, with the other critical disciplines contributing as well. And the shortage of child psychiatrists disappears, and higher quality, integrated care becomes available.
So don’t feel insulted. Using the cancer analogy, the most severe cases are likely going have to have the input from someone who has specialized and been trained in diagnosing and treating them. But if that person, where it be a child psychiatrist, a social worker, or a nurse, tries to do it alone in office based care, without a team of all the other needed professionals, it’ll be lousy care.
December 16, 2008 at 10:49 am |
Dr. Arnold asked, “Doctoral level professionals are more expensive –do we know whether they are better?”
Determining what is “better” is a highly subjective decision. Value is not easy to measure.
Again, to apply an economic analysis, let us assume that the marketplace of consumers, choosing what they believe to be best for their children, is what determines who or what is “better” as a consumable mental health product. The fact that child psychiatrists or other doctoral level professionals are far fewer than social workers and other non-doctoral providers is reflective of how our society values the services provided. At the “price points” of what a child psychiatrist or psychologist costs, versus what a licensed social worker or other counselor providing psychotherapy costs, the marketplace has found the optimal mix of those services.
Until we as a field increase the value of our services to society, the demand and supply for those services at the price we charge will not increase.
This is not something that central planning, through socialized medicine or government intervention can change. This is the reality of how society values what we provide. Dictating from Washington how those services are rationed to different segments of society will not change how society values them.
It may seem like a good idea for government to step in and subsidize our services so that more people can receive them. But just as the Big Three car manufacturers are flailing, because they can no longer produce a product that consumers are willing to buy at the price they charge, having the government step in and subsidize the product will not change how consumers value that product relative to other choices. It will not increase the intrinsic value of the product we provide, which is ultimately what determines how much society is willing to consume and to pay for it. It is up to us as a field to improve the product we offer, so that consumers will wish to pay for it.
I will grant that this seems an oversimplification, when most health care is paid for via private insurance and other third party payer systems (medicare/medicaid). Consumers do not consider the true cost of the fees the doctors charge when they make their decisions about how much health care they can afford, they only consider the out of pocket costs, in co-payment or non-reimbursed medical expenses. However, in aggregate, we as a society are still paying for those services in the monthly deductions from our paychecks for our health insurance and the taxes we pay to support the public health sector. Our society as a whole, through choices made by our elected legislators and by our corporations who fund the insurance benefits, as well as the millions of individual day to day decisions of each consumer about which health care provider they seek services from, and which insurance plan they are willing to pay for in their monthly paycheck deductions, are setting the value for our services and determining which is “better,” or the relative “betterness” (value) of doctoral and non-doctoral providers.
The value of mental health services is not determined by government funding, or government decisions. It is determined by the consumers of health care in the marketplace of health services. If we psychiatrists bemoan how undervalued and undersupplied our services are, because we cannot get the third party payers to pay for them, we have to realize that it is not the government or insurance companies who set our prices or determine the value of our services. It is us, who are providing those services, but demanding fees beyond what society is willing to pay, who are determining how society values what we do. If we want society to pay for more of our services, we can do either of two things (besides lobby the government to subsidize us, as Detroit’s Big Three are doing): we can lower what we charge for the services we provide, which will increase the demand, or we can increase the value we provide at the price we charge, which would also increase consumer demand. These are fundamental laws of economics that we cannot wish away.
We cannot change society by dictating through the government. We can only change what we as individuals do (and “we” as a professional group), and thereby change the effect we have on society and the value that society attaches to what we do. Our field must come to grips with this truth. If we want child mental health services to be as widespread and available as cosmetic surgery, doc-in-a-box clinics, or other economically successful health care products, we must provide more value that consumers are willing to pay for.
Lisa LaVardera-Guidice has made my point in her description of her own economic decisions regarding care for her children. I, too, am a parent of a child with ADHD and mood problems that require complex management. I am in the relatively unique position of being both a child mental health provider and a consumer. I am well aware of the economic decisions parents must make and the anguish that it can cause, wondering if the money spent for a child psychiatrist will be worth it, and feeling guilty that I would question the cost for my child’s mental health needs. These are the daily decisions that consumers must make.
Our field must find ways to provide more “bang for the buck” if we want our services to be more valued by society and thus in more demand and more available.
December 18, 2008 at 11:48 am |
Over the years there have been many conversations (at the federal and state levels) about the need to fix the child mental health system. The postings on this blog attest that there are many successful efforts underway; and many problems that persist. The key is access to services; ones that are both efficacious and the type parents/guardians want for their child. As mentioned by Jodi Groot, that includes the efforts of 1, 600 Advanced Practice Psychiatric Nurses who are certified to treat children with serious emotional disturbances. Thank you for brining together the voices of all who care about organizing these efforts.
December 18, 2008 at 4:50 pm |
Thanks, Kathleen. pj
January 6, 2009 at 2:46 pm |
One thing that frustrates me is the lack of mental health coverage when we have benefits that cover chiropractic care, acupuncture, and massage visits. Those are services I’m not convinced have great value and I would gladly swap them for mental health care. (We even have to have separate dental coverage which is needed by everyone.)
January 7, 2009 at 4:20 pm |
I agree with Sarah’s comment. I think stigma is at the root of this. But even if MH coverage were on par with other health services, as it already has been for some time in some states, we’d still have a broken system, due to the fragmentation, stigma, lack of standards, competition among disciplines, etc. So coverage alone will not solve the problem.
January 19, 2009 at 12:17 am |
Entered for John Schureman, PhD:
“I was one of the original opening persons for this blog, then a medical crisis forced me to cease participating in the exchange until I recovered enough “go juice” for me to return. The opportunity to revisit the two dozen exchanges provides me with an unusual vantage point for appreciating the whole range of perspectives. I cannot say I disagree with anyone’s contributions, taken as a whole; the dialogue is productive and inspiring.
Let me first say I am a community based clinician who has worked in the field since 1974, specializing in neuro-developmental disorders in 1997 to the present. I find working with a collaborative group essential, including paraprofessionals (in home service, school, and special care), educational consultants, neuropsychologists, physicians, social workers, and have even specially trained babysitters for my clients (one of many points Steven D. and I harmonize upon). I average 25% of my practice as a form of pro bono (exceptional low fee) while many clients pay top dollar for our services. The collaborative practice is structured to fit my community’s micro-cultural requirements, much of what we do would not be suitable for other areas. I am more than ever, skeptical and cynical toward the mental health profession and find my fellow licensed clinicians, astonishingly narrow and shallow in their knowledge and ability to think critically about their job responsibilities. Interviewing for clinical replacements while my medical crisis is dealt with has reinforced and amplified my views toward the utter incompetence of my community colleagues (another major shared issue with Steven).
Sara’s remarks I found to be insightful, accurate, comprehensive, sensitive, and deceptively profound in identifying the underlying problems we face in mental health. Her credentials as “mom of four children and friend to many moms,” makes her eminently qualified to participate in the dialogue. To begin with, the so called stigma around mental health is a socio-cultural illusion since in fact; all the members of her Psychology 101 class were and are coping with the problems of life that often become labeled “mentally disordered.” In order to manage our helping relationships, nomenclature is needed to conceptualize to problem that allows for the professional to become an effective change agent. The person is not the label, any more than the map is the territory, or the word is the thing itself. Diagnostic labels are only tools with a pragmatic use in helping resolve the person’s problem and not to define the person. The mental health professions tend to become sloppy in their use of language and Sara’s example of her visit to a clinician’s office provides an excellent example.
When any one, professional or otherwise, talks with a covert agenda of inferred pathology and is not working to hear and understand your experience of distress, the interpersonal connection becomes dysfunctional. R.D. Lang, a prominent British psychiatrist, referred to this form of communication as “mystification” and speculated that the interpersonal process occurs when one person attempts to improve their feelings of adequacy by lowering the other’s feeling of completeness. In this case, the clinician was likely to feel more a psychotherapist by creating discomfort in Sara, the patient as a child. Thankfully Sara’s mother had the good sense to be proactive, a rare occurrence in child psychotherapy. Probably her experience reinforces why so many of us rely on “hey, do you know a really good psychiatrist?” with friends. I am often given as such a referral, although I am not a psychiatrist.
Recently, as more cases have been referred to me because of negative prior therapeutic experiences, I have begun to conclude that unless one is really certain about the referral, perhaps a poorly informed consumer should stay clear of the clinical professions. Each week countless cases requiring relatively simple diagnosis and treatment are brought in under appalling circumstances that would be malpractice if not the community standard.
Sara’s profundity lies for me in her observation regarding the intellectual dissociation that is the standard amongst the clinical professions. I am continuously amazed to find the most reputable of highly educated and trained clinicians who treat concepts and scientific data about human consciousness as “stuff” to be practiced and fail to understand that we are all subject to the identical neurological processes. ”
John Schureman, PhD
June 2, 2009 at 2:51 pm |
Our seven pediatrician practice is engaged in a spirited discussion of prescribing psychotropic medications. We are all accustomed to prescribing stimulants, but only a couple of us prescribe anti-depressants or anti-psychotics. The rest of us are uncomfortable refilling these prescriptions while the primary care pediatrician is on vacation.
Are other pediatricians talking about this? We are working on a policy and I’d like to know what others think. Do others insist on a psychiatric evaluation at some point for patients on these medications? This is difficult with the shortage we face of psychiatric consultation.
I have even spoken to Risk Management as I feel we are all out on a limb on this one, with families desparate for help, demanding treatment, unhappy with various crisis centers and therapists, wanting to get medications from the pediatrician they have known for years. Yet I know I do not have the training or inclination or time to determine all that needs to be clarified before I feel comfortable writing a prescription for something like Zoloft or Prozac.
I am utterly uncomfortable assessing suicidality.
Any thoughts?
June 2, 2009 at 4:48 pm |
You and your colleagues are not alone! Because of the desperate need for guidance for Primary care practitioners (PCPs) in these other areas, at REACH we have developed an extended fellowship program for practicing PCPs in just what you describe. Also, working with leading PCP thought-leaders across the US, we have developed and published in Pediatrics the GuideLines for Adolescent Depression in Primary Care (GLAD-PC). This comes with a lovely toolkit of how to assess for suicidality, etc. We are soon to publish new guideines for managing aggression in primary care as well.
The big problem is that guidelines alone are usually insufficient to get folks really competent and comfortable, and sustained hands-on support is what is needed, which is what we do with our national faculty of PCPs and Child psychiatrists. Go to http://www.TheReachInstitute.org, and check out the training programs and outstanding national faculty. If enough of you are interested, we could schedule a pharmacotherapy learning or training experience at your location, as well as other areas of emphasis. pj Peter S. Jensen, MD
During our fellowship program, Do others insist on a psychiatric evaluation at some point for patients on these medications? This is difficult with the shortage we face of psychiatric consultation.
I have even spoken to Risk Management as I feel we are all out on a limb on this one, with families desparate for help, demanding treatment, unhappy with various crisis centers and therapists, wanting to get medications from the pediatrician they have known for years. Yet I know I do not have the training or inclination or time to determine all that needs to be clarified before I feel comfortable writing a prescription for something like Zoloft or Prozac.
I am utterly uncomfortable assessing suicidality.
Any thoughts?