WBUR

Mental Health Screening Exposes Access Problems

Massachusetts has more children’s mental health providers than most other states, routinely screens children for mental health issues, and has Rosie D., the 2006 lawsuit that mandates adequate mental health services for kids on public health insurance. But several challenges remain.

In the third report of our week-long series, “Are The Kids All Right?,” we delve into how doctors screen children in Massachusetts for mental illness.

BOSTON — Diagnosing a mental illness in a child is extremely challenging. Unlike an ear infection, you can’t see attention deficit disorder in a checkup.

Pediatricians have been confronted with behavioral issues for years, but they’ve never been given a screening tool to assess them.

At yearly checkups, doctors have asked parents about kids’ behavior: Are they playing well with others? Are they fitting in at school? But they haven’t done it in a systematic way.

With a new questionnaire, Dr. Greg Hagan, a pediatrician with Cambridge Health Alliance, says he’s catching more subtle problems. He remembers one visit with a teenager who filled out the new screening form before his checkup.

“He was just the sweetest, nicest kid, well-spoken, well-groomed,” Hagan said. “And towards the end of our 15-minute visit, I glanced at his screening tool and it was off-the-charts abnormal. And I said, ‘You know, I need to talk with you about this. What’s going on here? Because you seem doing OK.’ Very quickly it came out this was a kid who was being severely bullied and he wasn’t going to tell me about that.”

Being bullied could have severe consequences, such as withdrawal, anxiety, depression or suicide, as was the case with Phoebe Prince. Now, at every checkup Dr. Hagan gives parents a 35-question form to fill out. (See the form.) It asks things like: Does your child fidget? Is she having trouble sleeping?

“It doesn’t tell you that your child has attention deficit disorder just because you answer ‘yes’ to the question, ‘Is your child distracted easily?’ It initiates a discussion and it gives me, as the pediatrician, the opportunity to ask a lot more questions to drill down, if you will, on the child’s behavior.”

Pediatricians have been confronted with behavioral issues for years, but they’ve never been given a screening tool to assess them. Now parents who see problems with their kids can identify them clearly. This questionnaire was filled out by more than 360,000 families with kids on MassHealth, the state-run insurance program for low- and moderate-income families. Almost 8 percent were told they need more evaluation.

This process grew out of a lawsuit known as Rosie D., when a federal judge ruled the state wasn’t providing adequate mental health treatment. Now that’s changed.

“We’re a leader in screening from the standpoint of a statewide initiative,” said state Mental Health Commissioner Barbara Leadholm. Because of the lawsuit, she says, the state has revamped its services for kids on MassHealth.

“The child and family are at the center of the services, they are defining what we need,” Leadholm said. “And looking at other states, others have not done it in a statewide roll-out.”

For the kids on public insurance, that’s great news. But the new screening tool has also identified privately insured kids with mental health problems. In fact, an estimated 300,000 kids have diagnosable mental health problems in the state. In the private market there aren’t enough child psychiatrists and many don’t take insurance at all.

Dr. Gene Beresin, who trains child psychiatrists at Harvard Medical School, says the system is frustrating because it leads to long waits for treatment.

“It’s a dire problem,” Beresin said. “I mean most kids and adolescents who come for treatment have to wait 4-6 weeks in many clinics, some places 3-4 months.”

The long waits and the lack of programs led Marylou Sudders to say she would do something drastic.

“If I had a child with a serious emotional disorder in ... Massachusetts I would do everything I could to have them on Medicaid than on private commercial insurance,” said Marylou Sudders, of the Massachusetts Society for the Prevention of Cruelty to Children. (Jesse Costa/WBUR)

“If I had a child with a serious emotional disorder in ... Massachusetts I would do everything I could to have them on Medicaid than on private commercial insurance,” said Marylou Sudders, of the Massachusetts Society for the Prevention of Cruelty to Children. (Jesse Costa/WBUR)

“If I had a child with a serious emotional disorder in the commonwealth of Massachusetts I would do everything I could to have them on Medicaid than on private commercial insurance,” Sudders said.

That means she would quit her job, which is currently the head of the Massachusetts Society for the Prevention of Cruelty to Children. It’s a shocking acknowledgment of how bad private insurance is at covering mental illness, even though the state has a parity law that requires the same level of coverage for bipolar disorder as for diabetes.

But the problems can’t all be blamed on private insurance. Even when patients have access to care, as they do if they go to doctors in the Cambridge Health Alliance, they often don’t follow through.

“Unfortunately their ability to make it to a mental health appointment continues to be pretty low,” said Dr. Karen Hacker, an expert on child mental health screening at CHA. “I want to say running about 40-50 percent. Some never even make an appointment.”

A patient may have no way to get to a mental health clinic, or doesn’t go because the co-pays are high, and there is still stigma around mental disorders. The biggest issue statewide — and one we’ll explore more in our series Thursday — is the dwindling number of child psychiatrists.

So I asked Commissioner Leadholm, what’s the point of screening if there aren’t enough psychiatrists and psychologists who can help kids?

“That’s a very, very concerning question and it’s something we are all losing sleep over,” she said.

Even though she’s losing sleep, she says it’s still worth screening because eventually she believes the supply of mental health providers will catch up to the demand. For thousands of kids in the state with mental health problems who are waiting to find a doctor, it can’t happen fast enough.

Please follow our community rules when engaging in comment discussion on wbur.org.
  • http://www.facebook.com/people/Craig-Dune/100002055559017 Craig Dune

    I just heard it on the radio that “Wise Health Insurance” can offer health insurance for just $1 a day any one aware of this ? have anyone purchased insurance through them. I did search for them and found them online.

  • Nobody

    Diagnosing difficult? Just getting a therapist to return a call when you are looking for one is impossible. The therapy business must be booming so much that they can afford to not return calls. Or most therapists are loons themselves.

  • Guest

    Many insurance plans (mostly out-of-state) pass the cost of the screening tool onto the family.

  • Jesse A. Rieber

    I tried to download the childrens screening instrument discussed on the programme but it will not download. When I try to download it I am sent to another page covering world events. I a childrens psychotherapist with 20 years of practice and would like to see this instrurment. Help!

  • Anonymous

    This comment is in response to Sudder’s remarks: “If I had a child with a serious emotional disorder in the commonwealth of Massachusetts I would do everything I could to have them on Medicaid than on private commercial insurance.” There is a way to qualify for Mass Health for your child, even if you’re not low income. Apply for the “disabled child supplement” if your child has a diagnosed disability. This supplement will fill in holes in your private insurance, and qualify your child for mental health benefits through the Department of Mental Health. It’s a lot of paperwork, but it’s worth it. My child is receiving the help he needs because I took this step.

  • Margaret_hannah

    While it is a challenge to find mental health care, there is a program that is in subscibing communities within the Commonwealth. It is called Project INTERFACE and it is part of The Massachusetts School of Professional Psychology and their Freedman Center for Child and Family Development. Project INTERFACE http://www.projectinterface.org hosts a helpline Monday-Friday 9AM-5PM. Callers receive resource and referral counseling with matches made to therapists who take their insurance, have expertise in the area of concern, fit the location needs of the caller and do have an opening. Follow up services are also provided to ensure the caller has been to the therapist and feels matched.

    • Tracy

      Is this program for anyone? Sounds incredible. I will check it out

  • Esantelmann

    May I comment on my own comment? It actually took two steps… applying for the disabled child supplement through Mass Health, and applying to the Department of Mental Health to secure access to state services for my child. Help is there, but the system seems to discriminate against people not willing to persevere. The mental health system in Massachusetts is inefficient and can seem like a complicated labyrinth, and needs an overhaul for patients and their families to have easy access. Families already overwhelmed with a child with an emotional disability should not be burdened with navigating a complex system with different agencies who either compete against each other or don’t communicate with each other. Speaking as someone who has made it through the system, my best advice is to persevere, and pick up clues for next steps from each agency you speak with. Good luck!

    • Tracy

      well said both your comments. I thank you for bringing up the Mass health issue, I was going to but decided to read all comments first.
      Most people do not know that they can get mass health insurance as a secondary insurance, reguardless of income. I would advise and family with children who have dissabilities take full advantage of what they have to offer. There are many great programs now offered though the CBHI. I too have had to persevere to get what I needed for my child. Now I have it and am greatful.

  • Esantelmann

    May I comment on my own comment? It actually took two steps… applying for the disabled child supplement through Mass Health, and applying to the Department of Mental Health to secure access to state services for my child. Help is there, but the system seems to discriminate against people not willing to persevere. The mental health system in Massachusetts is inefficient and can seem like a complicated labyrinth, and needs an overhaul for patients and their families to have easy access. Families already overwhelmed with a child with an emotional disability should not be burdened with navigating a complex system with different agencies who either compete against each other or don’t communicate with each other. Speaking as someone who has made it through the system, my best advice is to persevere, and pick up clues for next steps from each agency you speak with. Good luck!

  • Connie Mills

    This is a great series, bringing many important issues to the forefront. Hope the conclusion includes discussion of intensive in-home services and how that type of assistance for struggling families can make all the difference for children. Youth Villages offers those services in Mass. and has recorded high success rates. Helping children with emotional and behavioral problems who have been in multiple hospitals, residential treatment, find success at home. http://www.youthvillages.org/mass Connie Mills

  • Kfitzgerald

    Screening for Mental Health, Inc. in Wellesley, MA offers online and in-person anonymous mental health and alcohol self -assessment to people nationwide. They also offer The Parent Brief Screen for Adolescent Depression (BSAD). The BSAD tool offers parents the opportunity to take a simple questionnaire online to help determine if their child’s moodiness is a normal part of growing up or something more serious. Visit http://www.mentalhealthscreening.org to find out more!

  • Susan

    “Unfortunately their ability to make it to a mental health appointment continues to be pretty low,” said Dr. Karen Hacker, an expert on child mental health screening at CHA. “I want to say running about 40-50 percent. Some never even make an appointment.”

    Once a hitting, punching, yelling child is too big to lift into a car and stay there until you can lock the doors, there’s little a parent can do to get the child to go to a mental health appointment s/he doesn’t want to go to. If the MH practitioner is not a good fit with the child, the child may refuse to return. Back to Square 1. This is in situations where an ambulance isn’t required. Obviously, if the child is harming herself or others, calling an ambulance is one way–but not for regular therapy appointments. What to do?

    I do think the screening tool should be mandated at all pedicatric offices in the state. Parents who have concerns often have no easy way to put their child’s behavior into words unless asked. The tool is a good way for a pediatrician or school guidance counselor to start a conversation that can rescue parent and child from the anxiety of not knowing what to do to get help.

  • disheartened

    this article still misses the point…there are numerous Child Psychologists/ but they will not accept
    ‘private insurance’ only Blue Cross and MassHealth. We have in past been turned away from:
    Franciscan Children’s Hospital, Childrens Hospital and McCleans b/c we did not have that specific insurance coverage.
    the bottom line, the very wealthy can get treatment and the very poor..
    Middle class families carry huge financial burdens on top of the stress of trying to help their children

    • Tracy

      get masshealth then. Anyone can get it. Unfortunately, you may not find much more options for child psychologists, but you will get much more help with them and the services they offer.
      Best of luck

  • Anonymous

    We commend WBUR for this important series. Massachusetts’ statewide mental health screening program is a national model.

    Using evidence-based screening questionnaires is an accurate and effective way to determine whether a child or teenager may have a mental illness. These tools take five minutes or less to complete and score, and can be administered in the waiting or examination room before an appointment. Research shows that teens are more forthcoming on a self-report questionnaire, than they are during a one-on-one discussion with professionals.

    While there’s clearly more to be done, this series has shown that screening is prompting important discussions in pediatric offices about issues that may have remained suppressed otherwise. Mental health checkups for adolescents are an important part of adolescent care — to help detect early signs of mental illness, and to reduce the severity of long-term psychiatric problems. They are an important step to ensure that our youth stay on track to achieve their life’s goals.

    Laurie Flynn
    Executive Director
    TeenScreen National Center for Mental Health Checkups at Columbia University

    • http://twitter.com/murmur55 murmur55

      Alliance for Human Research Protection – TeenScreen – “Under Intense Criticism Nationally” http://bit.ly/hICaWc

    • http://twitter.com/murmur55 murmur55

      Portrait of Laurie Flynn, TeenScreen’s Top Pill Pusher http://bit.ly/eeQKjQ

  • Anonymous

    More on mental health parity: The safe harbor for outpatient benefits, http://www.healthcaretownhall.com/?p=2973

  • Joe Forth

    At a conference on Transition-age (16-22 years-old) youth, a panel of youth, all of whom had received services through the MA DMH, was asked what made the most difference in their recovery. To a person they all said that having a DMH Case Manager was the single most important factor in their recovery. Some explained that having that one person that knows their history and understands both their needs and the mental health and educational systems and how best to access services was invaluable. I have listened to all of the series thus far and have yet to hear mention of this aspect of the treatment of mental illness in Massachusetts. Coming from a DMH case Manager, which I am, this could be dismissed as self-serving. However, I think that the youth we serve and most of their families and guardians really do value what we do as service coordinators and advocates for their needs.

    Thank you for covering the important issue of Children’s Mental Health.

    • Vivianprestondole

      My son is now 19 and had a wonderful DMH Case Manager for the past 4 years of his adolescence. However, when he transitioned to a new Case Manager this past summer (because he is now considered an adult), I have been very disappointed with the level of care. This Case Manager has canceled appointments, or just not shown up and it takes days for her to return our phone calls. My son has been completely dropped. I feel that DMH is either understaffed or the personnel serving the adult population is less professional than the staff serving the children and youth (since they have to be accountable to the parents).

  • Tom

    What long term outcomes do children and adolescents screened positive for mental illnesses realize subsequent to receiving typical mental health treatment? Specifically, how are they faring at 25 or 30?

    I entered the children’s mental health system at age 12. As an adult I collect disability. Am I alone in failing a system which putatively afforded me every opportunity for success?

    • Jean

      Some people might argue that collecting disability is a success, not a failure.

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