Treating kids with troubled minds: How to bridge the gap

Vermont pediatrician Thomas "Mike" Moseley III, MD, gained a window into a whole new side of his patients' lives when social worker Donna Laurin was hired as a member of the practice's treatment team more than five years ago.

While he thought referrals to mental health services would become simpler for his patients and their families, Dr. Moseley also found that the very nature of his practice changed. "I discovered that it has probably made us more aware of the problems that families face. It has made pediatric care more gratifying and, I hope, more useful for the kids."

The steps taken by this practice demonstrate one way of tackling head-on an issue that is surfacing throughout the nation: There are way too few child and adolescent psychiatrists available to meet the growing need for mental health services for young patients.

Only about 30 child and adolescent psychiatrists are in Vermont, said David Fassler, MD, who is counted among this group of specialists and is a clinical associate professor of psychiatry at the University of Vermont College of Medicine in Burlington. "If we had three times that number they would still be busy."

Additionally, the importance of mental health services for young people was recently underscored by the National Comorbidity Survey Replication, which found half of all lifetime cases of mental disorders begin by age 14.

The result: Primary care physicians are searching for and finding ways to bridge the gap.

"Our idea was to try to figure out a way to cope with a need we weren't trained for and weren't staffed for," said Dr. Moseley. "Being proactive about it gets you further than being run over."

Before hiring Laurin, Dr. Moseley's practice had the services of a child psychiatrist one-half day every month at the local mental health center. "Things are pretty thin on the ground here when it comes to the availability of services for kids with severe mental illness or even kids with what you might call the normal wear and tear of being an adolescent," said Dr. Moseley.

In Asheville, N.C., Sharon Sweede, MD, a family physician, also found a way to fill the gap in her solo practice by referring patients to a counselor who had an office in the same building. "People were much more likely to agree to see her than to go off to another office somewhere," she said. And such proximity can help the physician and mental health practitioner -- whether psychiatrist, psychologist, social worker or counselor -- form a more effective treatment team for a troubled child or adolescent.

More recently, Dr. Sweede has been involved in drafting physician performance measures for diagnosing and treating child and adolescent depression. The measures are being developed by the Physician Consortium for Performance Improvement convened by the AMA and should be available for comment in about two months.

Meanwhile, a publication on adolescent mental health is also being readied for publication by the AMA. It is based on presentations made at an educational forum last year.

Tools for the job

The need for such diagnostic tools appropriate for use by primary care physicians is great because there is often nowhere else for troubled children and adolescents to turn, said Dr. Sweede.

Plus, the question of when teen moodiness and angst has turned the corner and become a mental health disorder is one that physicians are being asked all the time, said Dr. Moseley. And there is no easy answer.

The cases now attended by Laurin can be incredibly complex and demonstrate the interplay between a medical condition and emotional and mental well-being. There is the young man who had a benign but destructive tumor. His family couldn't provide the care he needed. Then there was a girl with diabetes who was hospitalized 19 times in two years for diabetic ketoacidosis because she repeatedly ran away from home, leaving her supplies behind.

"A lot of what our kids need is out there but it's hard to make your way through the bureaucracy," said Dr. Moseley. The social worker can make it happen.

A great deal of care, even for serious problems, can also be provided within the practice, which is often where patients are most comfortable. Often, referrals to a building known as a "mental health" facility would be ignored, said Dr. Moseley.

"It has been a priority in Vermont and across the country to develop programs to enhance access to collaboration and consultation between child and adolescent psychiatrists and our colleagues in pediatrics and primary care," said Dr. Fassler.

Such efforts continue to evolve and emerge. Last fall, the New Mexico Dept. of Health and several other state agencies and associations sponsored a conference, Managing Child Behavioral Health Problems: Practical Solutions for the Busy Primary Care Provider.

The conference was designed to improve primary care physicians' diagnostic and treatment skills for attention-deficit disorders, depression, posttraumatic stress disorder, anxiety disorder and substance abuse.

Separate systems

However, improving skills is not always enough. There are often funding problems to contend with and, because of them, Dr. Moseley's first attempt at hiring a mental health professional didn't fly. The fee-for-service model failed in a population that is 70% Medicaid-eligible. What did work was a small grant from a local hospital, funds from the departments of health and mental health plus some "scrambling around and looking in the sofa for change," he said.

In general, the scarcity of funding tends to be exacerbated by the separate silos from which medicine and mental health operate. The systems are inherently different with medical health care generally acute in nature and mental health care chronic, said Kelly Kelleher, MD, professor of pediatrics at Ohio State University College of Medicine & Public Health and a member of the American Academy of Pediatrics year-old task force on mental health.

The delivery of mental health services is also plagued by reimbursement problems. Insurance programs, including Medicaid, generally cover only time spent talking to a patient. However, consultations with teachers at a child's school, for example, can be more important than spending five or 10 minutes with the patient, said Dr. Kelleher.

Vermont has taken steps to gain Medicaid coverage for the administrative time spent by child and adolescent psychiatrists and primary care physicians. Now payment is available for reviewing records, talking to a child's teacher and for phone calls between pediatricians and psychiatrists, said Dr. Fassler.

"We have a Medicaid waiver that creates a wraparound program so we can use Medicaid funds very flexibly," said Dr. Fassler. For example, "We can build in appropriate funding to support child and adolescent psychiatrists participating in school meetings."

Vermont also convened a group of pediatricians, family physicians, child and adolescent psychiatrists and school personnel to develop an attention-deficit/hyperactivity disorder tool kit geared to the realities of practice.

A similar activity is planned for childhood depression. "We look at a lot of these issues from a public health perspective and we are trying to do what we can to help each other and improve our collective ability to recognize and care for these kids," said Dr. Fassler.

Another collaborative effort evolved about 10 years ago in western Pennsylvania, after a large pediatric practice asked John Campo, MD, associate professor of psychiatry at the University of Pittsburgh's Western Psychiatric Institute and Clinic, to do some consulting for them.

The concept was admirable. "The group wanted to do more to care for children with mental health needs. There was no one else who could do it," said Dr. Campo. "But it was much more difficult to find a way to develop a sustainable program and not lose money hand over fist."

To plan their approach, Dr. Campo met with the pediatrician who formed the practice and the pediatrician's childhood buddy who directed the county mental health center. The three sequestered themselves on a boat in the middle of the Allegheny River and crafted an approach that is still working today.

It centered on county approval of the pediatric practice as a mental health delivery site, which generated some stable funding for the project. The resulting program is based within the pediatric practice but operates as a satellite of the mental health clinic.

The children identified as needing mental health services are seen by a nurse practitioner who determines which of three levels of care a child requires, based on severity of symptoms.

The collaborative approach seems key. "You can't just care for children once a month in an office visit that lasts 15 minutes when you have a problem that's 24-hours-a-day, seven-days-a-week," said Dr. Kelleher. "You have to have participation from the whole community."

Building on strengths

Back in Vermont, Paula Duncan, MD, a professor of pediatrics at the University of Vermont and youth health director for the Vermont Child Health Improvement Program, is working on early-intervention efforts to, among other things, help physicians get better at strengthening their young patients for the road ahead.

In addition to talking with children and teens about risky behaviors like smoking and drinking, and knowing how to pinpoint when they may be in crisis, she also counsels physicians to talk with young patients about their strong points. "There are data that show that kids with more strengths have fewer of these risk behaviors," she said.

She describes a conversation between a physician and young patient that could run as follows: "You've made some good decisions about not smoking and not drinking and not becoming sexually active and this is just one example of your being an excellent decision-maker. And you have other strengths that I've also noticed. You are close to your family, you have a couple of close friends, you are a good student and you are pursuing art after school."

Physicians often have special influence with children and families, said Dr. Duncan. One child told her after a visit that included such praise: "My mother has to feel that way about me, but when you said it, you aren't my mother and you aren't even related to me, so it must be true."