Health: Children in need

For four months, Kris Fronk waited.

  Waited as her young son’s rages worsened. As he began hearing and seeing things. As he suffered terrors in the night and tried to hoard knives in his room.

The mother had taken her son to a therapist, who suggested he suffered from severe bipolar disorder and recommended psychiatric help.

But it took four agonizing months for Fronk to get her son in to see a child psychiatrist and get that diagnosis confirmed, to get medications prescribed that would ease the turmoil in his mind.

“It was terrifying to see my child in that state and know that I could not help him,” says Fronk, of Calhan, Colo.

Fronk’s experience is mirrored in families nationwide, according to a recent report from the surgeon general that details a crisis in the mental-health care system for children. Among other problems, the report noted a national shortage of child and adolescent psychiatrists, which often translates into a long wait for an appointment.

“It’s hard to get in,” says Dr. Jeffrey Rinsky, a Colorado Springs, Colo., child psychiatrist. “And there’s a huge need.”

It’s not just a shortage of psychiatrists that causes children to fall through the cracks. Among concerns voiced by parents, doctors and mental-health professionals and generally reflected in the surgeon general’s report are:

-- Children with mental-health problems are not being reached at an early enough age.

-- Such services as inpatient care are lacking.

-- The stigma often attached to mental illness may prevent diagnosis.

 â- In urance restrictions and other pressures often mean there’s not enough time for proper evaluations and too much reliance on medications. Access to care, meanwhile, is restricted.

One in 10 children and adolescents in the United States suffers from mental illness severe enough to cause impairment, the surgeon general’s report says. Yet, in any given year, fewer than one in five receives treatment.

Before mental illness can be treated, it has to be identified. Better, earlier assessment and recognition of mental-health needs in children was one of eight goals outlined in Surgeon General David Satcher’s “National Action Agenda.”

Some mental problems, such as attachment disorder, can begin as early as infancy, says Dr. John Cantwell, medical director for Devereux Cleo Wallace, which operates mental-health facilities in Colorado Springs and Westminster, Colo.

“One of the issues that’s critically important is early identification and assessment of kids, starting at the preschool level. ... It’s clear that the earlier you identify the problem, the better the chances that you’re able to come up with solutions to that problem,” Cantwell says.

Satcher says everyone who works with children — teachers, coaches, health-care workers and others — must be better educated to recognize mental health problems so that they can alert parents.

But the effort must begin with families, Satcher says.

“We need to help families understand that these problems are real, that they often can be prevented and that effective treatments are available,” he said in releasing his report.

Parents who are aware of a problem shouldn’t assume children will grow out of it, says Fronk, who helps lead a support group for parents of children with bipolar disorder and other mental illnesses.

“The problem is that they don’t grow out of it. The only thing that happens is their disorder matures as they mature.”

Cantwell said he would like to see primary-care physicians put more emphasis on mental health. He advocates family physicians and pediatricians routinely performing some type of emotional-behavior assessment that could point to possible problems.

The idea is a good one, says Dr. Harry Anderson, president of the Pikes Peak (Colo.) Pediatrics Society.

But implementing it, he says, would be tough in the face of time pressures and reluctance by families to address mental-health issues.

Family, teachers and even doctors may resist a diagnosis because of concern that a stigma will follow the child, says Brenda Heimbach, division director of outpatient services for children, families and adults at Pikes Peak Mental Health in Colorado.

Such reluctance, however, can hurt the child more than any label, she says.

“If you’re a 10-year-old with depression, if nobody wants to label you as depressed because they’re worried about a label, then this 10-year-old is not going to get any treatment.”

Finding a psychiatrist
Identifying the problem, of course, is just one side of the coin; treating it is the other.

According to the surgeon general’s report, pediatricians often report difficulty referring seriously ill patients to mental-health specialists. And insurance coverage for children’s mental health is spotty nationwide.

And there are gaps, such as anxiety disorders.

“Our insurance laws don’t cover a lot of the mental-health issues that children have,” says Jeanne Mueller Rohner, executive director of the Mental Health Association of Colorado.

And even when problems are covered, care may be tough to get.

When Fronk was advised to get psychiatric care for her son, Joseph, she turned to her insurance provider’s list of child psychiatrists. But out of that list of 40 or so names, several were no longer practicing. Many others weren’t taking new patients or wouldn’t take patients as young as Joseph, who was 5 at the time. Fronk ended up having to take her son to a psychiatrist far from home, though recently she was able to change to a local doctor.

Similarly, it can be tough for doctors to keep track of which psychiatrists take which insurance or which see a certain age group of patients, says Anderson.

“A big issue is that the primary-care physician, be it a family practitioner or a pediatrician, sees a lot of this stuff, and we need to know where to refer them to. ... Some of us can offer some elements of treatment, but a lot of it requires ongoing psychotherapy.”

Also contributing to the problem, he believes, is a general lack of communication between primary-care doctors and mental-health professionals. He also notes the piles of paperwork often required for referrals.

Emphasis on
outpatient care
Heimbach says there’s a lack of hospital beds but notes that more emphasis is being placed on outpatient services and less on hospitalization. And that can be a good thing, she believes.

In some cases, children used to languish in a psychiatric hospital for years, then turn 18 and go to the adult unit, she says.

“That’s hardly preparing kids to interact in society. ... There’s more pressure on outpatient services to be more effective in meeting people’s needs.”

Cantwell says its important for children to be handled in the least-restrictive setting that serves their needs. But he worries that those who need long-term care may be left out by insurance restrictions. And he’s concerned that those restrictions put too much focus on medications while not always allowing adequate time for assessment.

“There’s pressure more and more to rely on medications, because medications are cheaper than services,” Rinsky agrees.

That pressure also comes from parents, Anderson says.

“Parents don’t want to use mental-health services a lot. ... The therapy isn’t, ‘Here’s a pill, you’re fixed.’ That’s what they want. They don’t want to go to therapy. It’s a real problem for all of us.”

No one has an easy answer for all these problems. Rohner believes it will require a change in priorities. “As long as we’re OK with putting money into prisons instead of earlier treatment and prevention, then I think we’re going to be in trouble.”

THE NUMBERS
-- At least one in 10 children and adolescents in the United States has a serious emotional disturbance that disrupts his or her ability to interact with others.
-- As many as one in 10 young people may have an anxiety disorder.
-- As many as one in 33 children may have clinical depression.
-- Almost one-third of 6- to 12- year-olds diagnosed with major depression will develop bipolar disorders within a few years.
-- Anorexia affects one in every 100 to 200 adolescent girls.
-- Suicide is the third-leading cause of death for 15- to 24-year-olds and the sixth-leading cause for children ages 5 to 15.

-- Source: U.S. Department of Health and Human Services, American Academy of Child and Adolescent Psychiatry