Health Policy$ense

Beyond Pills: What Will It Take to Transform Children's Mental Health Treatment?

Insurance Systems Must Provide Access to Reasonable Treatment Choices at Costs That Are Affordable to Families

If you have read the news lately, you may have noticed two very different types of stories about children's mental health.

The first type of story documents an alarming proliferation of mental health diagnoses among children and adolescents. Since the early 2000s, the percentage of children diagnosed with attention-deficit/hyperactivity disorder (ADHD) has increased more than 50%. Similar patterns
Brendan Saloner
Brendan Saloner, PhD, is a Robert Wood Johnson Health and Society Scholar at the University of Pennsylvania'a Perelman School of Medicine.

can be found for other conditions such as autism and bipolar disorder. This increase in diagnosis rates has been accompanied by a steady increase in the number of children treated with stimulant medications, such as Ritalin and Adderall.

In The New York Times, Alan Schwarz provides a detailed account of how major pharmaceutical companies became increasingly aggressive in marketing ADHD – and the pills to treat it – to anxious parents, teachers, and pediatricians. The result, Schwarz argues, is the growing medicalization of normal childhood problems. To give one memorable example, the tag line for a 2002 advertisement for Adderall reads: "Thanks for taking out the garbage."

Yet for all the talk of medicating kids who forget to take out the garbage, there is a second story.

Broken treatment system
This story, which surfaced in the wake of the 2012 Newtown shooting, documents a broken treatment system, where families with children in dire need wait weeks – or months – to find the right treatments, often at great financial burden to the family. Lori, a mother of a seven-year old with bipolar disorder was profiled in a Reuters story. Lori's son suffers from extreme anxiety and is prone to outbursts. Lori says, "We fight with doctors, our insurance company, educators, each other; the list goes on and on ... It isn't even a system. It's not like there's a call center to help you figure out what to do and how to get help."

At first blush, it seems difficult to reconcile stories like Lori's with a world of rampant over-treatment. How can it be that millions of children that don't need treatment are getting pills, while many others that do need professional help are kept out of the system? In fact, both narratives reveal important truths that can help advocates and policymakers lay the groundwork for mental health system reform.

Let's start with the question of prevalence. There is no universally accepted estimate of the number of children in the United States that meet clinical guidelines to be diagnosed with a psychiatric disorder. Best guesses, which come from household surveys in which non-clinician interviewers ask parents structured questions about their child's mental health problems, range from 13% to 20% of all children. These studies are seldom conducted across multiple years, so we have no benchmark estimates of mental health impairment to compare to changes in diagnosis rates. Thus, the question of how much the surge in diagnosis rates actually reflects changes in the prevalence of mental health problems among children is still not known.

Sparse access
We do know that access to treatment is sparse for those children that do need help. In a study published this month, my colleagues and I tracked the treatment patterns of youth in the general population with mental health problems over a two-year period. Across all age groups, we found that fewer than half of all children that need treatment receive any assistance. We also found that most experiences in treatment were very brief and would not meet even modest criteria for clinically adequate treatment (which we defined as at least 8 visits with a provider for counseling, or at least 4 visits with a provider while the child was beginning treatment with a psychotropic medication). Only about one third of treatment episodes met our criteria for minimal adequacy. Indeed, a large fraction (about 40%) of children only go to a provider once to receive a diagnosis or consultation, and never return for follow-up treatment.

mental health

There are three issues that must be addressed in order to improve these dismal outcomes. First, families need better education. For example, the National Stigma Study presented adults with vignettes about children with common mental illnesses – ADHD and depression. Few adults recognized the symptoms, and most did not acknowledge that the children in the scenarios needed clinical attention. Basic facts about mental illness are never communicated to parents and teachers. In the place of good information, stigma is pervasive, misinformation is rampant (including the widespread perception that individuals with mental illnesses are generally dangerous or unstable), and opportunities to screen children for mental health problems – and engage them in effective treatments – are missed.

Better trained primary care providers
Second, we need to equip primary care providers with better training and resources to diagnose and treat mental health disorders. Our study found that most children who receive treatment get their care from a non-specialist such as a family doctor or pediatrician. These doctors – who see everything from irritable infants to adolescents with acne – do not necessarily have the training or time to make a careful diagnosis of ADHD, depression, and other disorders with complex symptoms. Although professional organizations, such as the American Academy of Pediatrics, have issued treatment guidelines, providers are often unaware or do not follow these guidelines. Dosing guidelines for psychotropic medications are not always adhered to, and follow-up after initation of medication treatment is poor in many settings. Pediatricians may also lack the ability to refer their patients to psychotherapy, social skills training, or family-based interventions that show promise for many groups of children with mental health problems.

Third, and related, both public and private health insurance systems must provide access to reasonable treatment choices at costs that are affordable to families of children that need treatment. Two recent policy reforms help. The 2008 Wellstone-Domenici parity law requires virtually all health insurance plans to eliminate lifetime limits on mental health coverage (where previously some plans had required enrollees to pay out-of-pocket for treatment after a cap was exceeded) and also requires plans to offer the same number of annual visits for mental health care as for other physical health conditions. Final rules were publicized in late 2013.

Extended parity
The Affordable Care Act extends parity. It eliminates insurers' ability to disqualify or charge higher premiums to individuals with preexisting conditions (a common tactic among insurers seeking to eliminate costly patients). It also includes mental health and substance abuse treatment as essential benefits, meaning that insurers on the exchanges are required to include these services in their benefit packages. Subsidies for low-income families may help some low-income children to get enrolled in better plans than those previously available on the individual market or through employers.

These are encouraging first steps, but they must be met with further actions to ensure that health insurance plans offer enough good choices in their network of mental health specialists. The quantitative measures of treatment quality are important to measure – how many kids that need treatment are experiencing delays? Who drops out of treatment? Subjective experience matters too. Taking children's mental health care seriously means investing much more in talking with families about their options, and providing them with resources to pursue alternatives. When families are empowered and informed, they will be able to better decide for themselves whether pills – or other treatments – are best able to meet their needs.