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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.

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