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Mental illness is an increasingly common condition among California’s children, yet the state lacks a coherent system of care. In 2018, the California Children’s Hospital Association (CCHA) convened a workgroup to discuss this emerging crisis, and now has released a report offering recommendations for action. CCHA President & CEO Ann-Louise Kuhns, discusses the report and what needs to be done.

Q: Why did the Children’s Hospital Association choose to focus on mental and behavioral health at this time?

We were hearing more and more from our hospitals that they were seeing a real increase in children and youth in crisis in their emergency departments. They were very concerned that many of these children who were in psychiatric distress had never received any previous behavioral or mental health services before coming to the emergency room.

We felt that we had to try to understand this issue better, come at it thoughtfully in a holistic way, and develop recommendations to address this crisis.  If children are able to get culturally appropriate services in their communities they won’t be coming to emergency rooms, which are the most expensive places for treatment and the most distressing for the child and family. 

Q: Can you say anything about why the number of children requiring mental health services has grown so much in recent years?

Our work group of clinicians identified multiple possible factors, including better recognition and diagnosis of mental health disorders; potential negative impacts of social media on some children; substance abuse in teens with mental health issues; and increasing social and economic strains on families.

We also are losing mental health resources right and left. We don’t have enough psychiatric inpatient beds, and there isn’t parity in the availability of coverage for mental health services. One clinician said it’s sort of like a perfect storm occurring in our society right now, and our kids are paying the price for it.

Q: Our audience is particularly interested in children with chronic complex conditions. Can you comment on the findings in this area and what you hope for?

We know anecdotally from talking to hospital leaders that children with co-occurring mental health issues and chronic physical conditions face particular barriers in trying to access services, including two instances where a child was in a hospital for over a year because no suitable placement could be found.  That’s completely unacceptable.

There’s a real gap in the California Children’s Services (CCS) program, which covers very little in the way of mental/behavioral health services even though children on CCS with complex conditions are more likely to face co-morbidities, such as depression and anxiety. Assistance should be available through Medi-Cal, but that program is really falling short. The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program requires treatment, so every child in CCS with mental health needs should be able to access those services. Clearly this is not happening. The Department of Health Care Services reports that in state fiscal year 2016-17, less than 5 percent of youth enrolled in Medi-Cal received a single mental health service. Obtaining mental health care is difficult for anyone, but being in CCS just adds another layer of complication.

Another challenge is that in California mental health services are divorced from the physical health side, so county mental health plans are responsible for treating common diagnoses such as ADHD and depression. Absurdly burdensome county paperwork makes it difficult for clinicians to find time to provide treatment. It’s a nonsensical structure that needs to be addressed.

“CCHA’s priority this year is to try to improve the mental/behavioral health workforce for children. It’s estimated that California has only one-third of the psychiatrists we need, and half of them are over age 60. So there is a serious shortage, even for privately insured children.” 

Q: Your focus is California, but obviously this is an issue in other states. Do you think this paper’s recommendations are generally applicable elsewhere?

I think some of our recommendations, such as those having to do with enforcing mental health parity, are a national issue. The need for earlier intervention for children and adolescents also is universal. There’s a crisis for children across the board, across the country. Trying to help build resilience in children and help support families would be a good investment in our future, both in California and nationally.  The same is true of our recommendations about supporting primary care providers to manage patients in their community practice so that children don’t have to wait so long for psychiatric treatment. We know that’s a model that works. 

Q: Obviously there are many obstacles to providing care, and you’ve developed multiple recommendations. Who should lead the charge?

I think the state has to lead it. Governor Newsom has indicated that he wants to lead, and we’re very encouraged by the individuals he has appointed to key posts. This is a really complicated problem that will not be solved easily or quickly, and it can’t be accomplished without the state. We are going to need additional funds, and the state must encourage and incentivize standardization among counties in the way they approach and treat children’s mental health. EPSDT must be enforced, and the state also has power of enforcement over private health plans. We all need to help the state be successful.

Much also can be done at the local level, where mental health services are provided. There may be opportunities for counties to collaborate, especially in rural areas where there are large gaps in community-based services.

Q: How optimistic are you about creating a better system?

I think we can make change, though not overnight. CCHA’s priority this year is to try to improve the mental/behavioral health workforce for children. It’s estimated that California has only one-third of the psychiatrists we need, and half of them are over age 60. So there is a serious shortage, even for privately insured children. There are some obvious things we can do that would immediately affect access to care, such as reducing burdensome paperwork so clinicians can spend more time with kids. We also hope the state will create a standardized assessment tool for counties, which is probably harder than it sounds, but is doable. We will be looking for funding in the state budget for more training for psychiatrists and the psychiatric workforce generally. We think supportive tele-consultation for primary care physicians will enable children to be served in their own communities. The Association initially will be working on these issues. Other important goals are for the state to enforce existing laws, and to support early intervention programs, such as Help Me Grow – which helps to provide support for families of young children – that have had success.

Q: What can families and providers do individually to bolster improvements in mental health services?

It would be great if families and agencies could really articulate to legislators and leaders just how important it is to invest in children. That’s where we will see the long-term payoff. We lose sight of the fact that if we don’t make these early investments in kids, we’ll pay in the long run. We need healthy children and families if as a society we want to have healthy adults. We must remind leaders not to neglect children in discussions of mental/behavioral health.

Q: Anything else you’d like to note?

The good news is that we are now more aware of mental health issues for children.  Our task is to take what we know and use that information to reduce the stigma around mental health treatment to make it easier for families to ask for services, and build the infrastructure so that children can obtain those services.  Our report identifies a number of shortcomings in California’s system. I am optimistic because there is now some new focus, and I hope that parents who have a child struggling with mental illness know that they are not alone, and many people are trying to make it better.


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