Stakes High For Improving Mass. Children's Mental Health System

All this week in our series, “Are The Kids All Right?,” we've gotten a glimpse of some of the deficiencies in children's mental health care in Massachusetts.

Some of the challenges we've heard about include: the shortage of pediatric mental health care providers; the difficult choices parents face about medicating a child; and how early we can or should start looking for signs of mental health problems.

To close our series, we hosted an in-studio discussion to explore what can be done to improve care in the state. WBUR Morning Edition host Bob Oakes was joined by Barbara Leadholm, the state Department of Mental Health commissioner, Lisa Lambert, executive director of the Parent Professional Advocacy League, and Dr. Gene Beresin, director of Child and Adolescent Psychiatry Residency Training at Massachusetts General Hospital.

Deborah Becker and Monica Brady-Myerov, who reported this series, produced this conversation.

[transcript]

Bob Oakes: Let me ask you first: Explain why all of this should matter to me and everyone else on the other end of the radio. The question is, why is pediatric mental health care important to people who are not necessarily personally dealing with it?

Beresin: It's a huge social issue. I mean, if we look at the numbers, between 10 to 20 percent of kids in adolescence have psychiatric problems. Most of these go into adulthood, which leads to unemployment, disability, and in childhood, school problems, social isolation, substance abuse, difficulty with academics, school dropout.

Leadholm: I think it's important that people realize that kind of mental health and a sense of well-being is very, very important to a child and kind of successfully growing up.

Commissioner, if it's important for identification and treatment to begin early, what can be done to make sure that kids actually get the care they need early on?

Leadholm: As you've noted in earlier discussions this week, screening, talking, really, with your pediatrician. I think raising the issues, and as a pediatrician or a pediatric team, they're being sensitive and actually screening for a behavioral health issue.

Lisa Lambert, listen to this with us. We started our series this week with the story of a family. One of the five children in the family, who is 17, has had several diagnoses, has tried several medications, has been hospitalized four times, started self-medicating and went through substance abuse programs. His mom described what it's been like.

So I just kept taking him in to therapists. Everything was chaotic. I didn't know what he was doing but I knew he wasn't doing the right things, and I couldn't have any control.

Lisa, are stories like this common?

Lambert: They're very common. Most parents are the first people who ever see anything, any signals or any sign, that something is amiss. And they don't know what to make of it because most so-called "symptoms" for children's mental health are behaviors we see in all children, only they're more intense, or you see them more frequently. So the parent is sort-of throwing up their hand saying, "I have a gut feeling." Then they go through a series of opportunities or visits or appointments and frequently what happens is people add on diagnoses or add on advice and it becomes more and more muddled for the parent.

Lisa, the family I just mentioned also said that they had a problem finding a doctor. Repeatedly throughout our series, people told us essentially the same thing. Is this the biggest problem?

Lambert: Access to care, I would say, is the No. 1 problem that parents face.

Gene Beresin?

There's a real shortage of providers. I mean, there's 7,000 child psychiatrists in the United States for 7 to 12 million kids. There's 21 per 100,000 in Massachusetts, and we have the richest numbers of child psychiatrists in the country.

But, can we do anything to encourage the training of psychiatrists, to put more psychiatrists out there in practice? Will we ever solve that problem, Gene?

Beresin: I hope so, but it's going to take funding. For example the federal government has had major cutbacks in specialty training. There are only 320 child psychiatrists graduating nationally because that's all the funding that's available.

Commissioner, let me ask you this question: What's Massachusetts doing to try to address that?

Leadholm: One of the things that the state has done, something we call the Children's Behavioral Health Initiative, is we're adding through MassHealth a span of services that go beyond medication. We're really looking at in-home treatment. We're looking at family partners, parents with lived experience who have learned how to navigate the mental health system. We're teaming them up with families and children who need access to services.

Lisa Lambert, does that sound good to you? Does it sound like it's the right way to go?

Lambert: It's a new, innovative way that many families are giving a thumbs up to.

Lets talk for a couple minutes about something Lisa was mentioning a few minutes ago, and that's navigating the difficult system of trying to find care and how to coordinate care. We heard from many families talking about that difficulty. We spoke with two parents, Robin Friedlander and Tom Haunton, who say they've spend hours coordinating care for their daughter with the objective of keeping her out of the hospital.

None of it is easy.

If everybody played by rules..

...If anybody would explain what the rules were. I don't even know what game I'm playing, nevermind the rules, it's just too out there. But I will do all of it to keep her from going back into that hospital. Every phone call, every e-mail, every person I have to explain whatever to, I will do 10 times over rather than putting her back there.

Do you think this problem can ever be adequately addressed? Commissioner?

Leadholm: I think, really, the system needs to be complicated because children are developing...

Needs to be complicated?

Leadholm: Well, I'm gonna explain what I mean. Children are complicated beings. And we have to, when you're looking at a child — and Lisa started the conversation out by this — we don't know if this is normal behavior, or if it is more intense, or less intense, and we don't want to put a label on a child needlessly. And I think it's very important that we do a thorough assessment, and that means the diagnoses can change because a child is growing up.

Let me ask a question about insurance, private insurance. We have a parity law in Massachusetts, so mental health issues are supposed to be covered, just as other medical issues are, but there are many private insurers who do not cover some mental health services. A former state Mental Health commissioner told us that insurers are complying with the letter of the law, but not the spirit of the law.

Commissioner Leadholm, I'm wondering, what might be done so families on private insurance get the same level of service as families using public assistance?

Leadholm: The Department of Mental Health and the Division of Insurance are working together to really look at the implementation of parity. And we are reviewing how it is being implemented in Massachusetts and definitely this is something we'll be taking a serious look at.

So when are you going to come out with something that's going to deal with that issue?

Leadholm: We're looking at really reviewing this actively now and meeting with the insurers over the next several months. And so I would say, depending on how those conversations go, we're really looking at the next three to six months.

Beresin: I'm hopeful but I'm worried and I can tell you why. For example, the insurers might say, "If you have a diagnosis of, say, depression, you could have unlimited visits because it's 'biological'" and what that means is 15-20 minute "med" visits. Well that's totally insufficient for treating a child who is truly depressed and has a number of other academic and social problems.

Usually when we have a roundtable, we probably end on a positive note where we ask you to say something positive about what's down the road, but we're going to flip that on its head this time and ask this question: what's at stake if the system does not improve?

Lambert: I would say if the system doesn't improve, then people, many people, will simply give up in the system and look for other ways to figure it out. And some of those ways might work, but many of the people will feel disenfranchised.

Leadholm: Our future. Children are our future, and so from my standpoint, this is a call to action for all of us to really invest in the future, to invest in families, and to really help children grow.

Beresin: I think we have to put mental health on the same table as other medical problems, and I think we have to understand that the emotional growth and development of our children, as Barbara said, is as critical as taking care of diabetes or other lifelong problems. We have a spectrum of problems. If we can educate, de-stigmatize families — one in four of our listeners has somebody in their family that has a problem. It is one of the largest problems and yet we've been hiding our head in the sand.
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Editor's note: Some parts of this interview were edited for clarity.