The goal: To help kids with serious mental health issues

Commentary. By Charles Atkins, MD, amednews contributor. March 13, 2000.

COMMENTARY

Observations on the state of medical practice and medical life

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Around the country we see more children on psychiatric medications than we have ever seen before. We read high-profile horror stories of children acting out in violent ways; then we learn that the perpetrators are being treated for depression and other disorders. Beyond the anecdotal, which I'd argue is the tip of the iceberg, stand chilling data.

The 1997 Youth Risk Behavior Survey out of the Centers for Disease Control and Prevention revealed a number of interesting statistics.

One in five high school students contemplates suicide in a given year. Eight percent of high school students report that they have attempted suicide at least once in the preceding 12 months.

And we know that the top three killers of children, adolescents and young adults are accidents, homicides and suicides.

To the argument that "this has always been the way," I counter with the facts that suicide and homicide rates for teenagers have risen threefold and fivefold, respectively, since the end of World War II. Something both quantitative and qualitative has occurred.

So why is this happening and what are we doing about it? The whys, like the whys for violence, are quite similar. What we find is a combination of nature and nurture. Children and young adults are exposed to a barrage of risk factors that lead to both externalizing (violent, aggressive and out-of-control) and internalizing (depressed, anxious and withdrawn) behaviors and syndromes.

The laundry list of damaging factors includes: exposure to violence in the family, the community and the media; low socioeconomic status; broken and disrupted families; family histories of depression; active substance abuse in one or both parents; coercive parenting; abuse -- emotional, physical and sexual; use of drugs and alcohol; early sexual activity; poor school performance; and on and on.

What we find when we look at all these is that it's not a single risk factor that leads to the negative outcomes of depression or out-of-control behavior, but it's the child with five or more of these negative hits who will manifest symptoms.

Allow me to add one more damaging factor: managed care.

Not long ago, the Hartford Courant ran a four-part commentary on the state of mental health services for children in Connecticut, which is where I practice. In researching my books I came to realize that what occurs in my state is a decent measure of the country at large. What the Courant revealed was that since the advent of managed Medicaid in 1995, the reimbursement for inpatient services for children and adolescents over a two-year period was cut by more than 50%.

The idea was that managed care would decrease the time children were in hospitals but would enhance outpatient services. This didn't happen, however; and over the same two-year period reimbursement for ambulatory behavioral health care was cut by over one-third.

The reality is that parents of children who aren't at imminent risk of hurting themselves or someone else won't be able to have them evaluated in a timely fashion. It is in no way uncommon for such parents to have to wait periods of more than one or two months.

A year ago I helped establish a clinic in conjunction with our local school system to work with some of the more profoundly ill children in the community. What I quickly discovered is that the managed care companies contest almost every single day of treatment -- much more so than they do with adults.

It's standard practice for them to demand physician-to-physician reviews that can last anywhere from 10 minutes to more than half an hour. All of that is time where two highly trained physicians are battling for a day or two of service for a child who is failing in multiple spheres of their life. Objective outcomes of this flagrant denial of care have resulted. As children are pushed out of the hospital too quickly, readmission rates have risen.

A more disturbing phenomenon is the pressure from insurers to rapidly begin medication. The relative number of children in treatment who are on psychotropic medications has risen dramatically. I've had conversations with managed care social workers who will berate me for not starting medication after an initial evaluation. I've been flat-out told that if a medication is not started, adjusted or added to, the unit of service will be denied.

For anyone who has spent time treating children -- and I am not a child and adolescent psychiatrist -- you realize that the developmental and cognitive state of the child makes the evaluation lengthier if you want to be accurate.

A 5-year-old who tells you that he hears voices could be psychotic, or maybe he just has an active 5-year-old imagination with all of the magical thinking that is appropriate to an age where you can grab a dish towel, throw it around your shoulders and race through the house screaming, "I'm Superman."

The rays of light, and they're real, will not come from managed care. They're coming from communities that are waking up to the fact that these are children who should be treated sooner rather than later.

Locally, we've pursued and recently received a federal grant to help establish a therapeutic school, among other things. Beyond that we've set up an endowment through my hospital to try and underwrite services for local children with serious emotional and behavioral problems.

I'm not above begging; while I hate to cave in to the aversive behavioral techniques of the managed care companies, I'd rather spend a half hour educating a room filled with potential donors than haggling for two sessions for a child who needs treatment measured in months, not days.

I hope everyone reading this will look to their own community and their own level of involvement. The good news is that effective treatments exist that can get a child who's fallen off the developmental curve back on. Our charge is to act, to face the problem head on and find each of our roles in doing something to help.

Dr. Atkins is the director of psychiatry at Waterbury (Conn.) Hospital and a member of the Yale clinical faculty. His latest thriller is "Risk Factor" (St. Martin's Press).