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Screening children for mental health issues may not guarantee care

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Six years after the state launched an unprecedented effort to address the mental and developmental needs of young children, doctors in Massachusetts are screening more children for behavioral health concerns than any other state.

Nearly 7 in 10 Massachusetts children under age 6 in low-income families were screened in 2011 and 2012 — more than twice the rate in the United States as a whole, according to data released this month by the Massachusetts Budget and Policy Center as part of the national Kids Count report. Doctors in North Carolina, which had the second highest rate, screened just over half of this group of children.

“Massachusetts is an outlier — in this case, an outlier in a good sense,” said Noah Berger, president of the policy center. “We have made significant changes.”

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But, has the success of pediatric screening led to better behavioral health care in the state? That’s a question researchers and physicians say they can’t yet answer.

Doctors were required to screen children who are covered by Medicaid after the state lost a landmark court case in 2007. A federal judge determined that the state had failed to provide good early diagnosis and treatment for poor children with mental illness.

The screenings, a questionnaire that parents fill out before a regular check-up with the pediatrician or family doctor, were meant in part to identify young children who could benefit most from early treatment, in some cases avoiding long-term problems. They are not used to make a diagnosis.

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As many as 1 in 5 children experience some sort of mental illness or developmental disorder in a given year, though a smaller number are seriously impaired by their condition. In 2012, about 7.5 percent of screening checklists identified a behavioral health need among children on Medicaid, according to state data.

Certainly doctors and families can’t address a child’s condition if they don’t know about it. But getting the children who are flagged by the screenings connected to the care they need remains a major challenge.

Doctors and advocates cite a host of obstacles: inadequate mental health training for primary care doctors, a dearth of pediatric psychiatrists, and persistent stigma around mental illness that makes some families reluctant to talk about the issues their child is facing.

It is difficult to track how often a positive screening leads to appropriate follow-up care; the state Medicaid program has begun reviewing data but has not released any figures. Sometimes the first step is simply an in-depth conversation with the pediatrician. And, if a doctor refers families to a specialist, the family doesn’t always make, or keep, an appointment.

“Mental health screening is not the same as screening for anemia or lead poisoning,” said Dr. Karen Hacker, a former director of the Institute for Community Health at Cambridge Health Alliance. “It’s how people feel and how they identify their symptoms, and it’s at a given moment in time.”

Some pediatricians were initially reluctant to start screening their patients. The feeling, said Dr. John Straus, director of the Massachusetts Child Psychiatry Access Project, was “don’t screen, if you can’t do something about it.”

The Psychiatry Access Project provides primary care doctors with telephone consultations with psychiatrists, to guide them in treating children who have signs of ADHD or simple depression or referring more serious cases to a specialist.

Some pediatricians began screening most patients, not just those on Medicaid, as they became more familiar with the checklists and as commercial insurers began paying them to use the tools — typically a few dollars more than the $9.73 that Medicaid pays.

As screening in Massachusetts has grown, so has demand for physician consultations with mental health specialists, Straus said. His program is used each year by about 88 percent of primary care practices that see children, he said.

The access project has become a national model for filling the gaps in pediatric mental health care. Because a mother’s mental health affects her child, there are now efforts to expand the program to collaborate with obstetricians to screen mothers for mental illness during pregnancy.

Straus, who also works for the Massachusetts Behavioral Health Partnership that manages the mental health needs of many people on Medicaid, said the pediatric screening tool has succeeded in starting the conversation about behavioral health with parents, even if they are reluctant at first to acknowledge problems.

“It’s sort of like asking, how many cigarettes do you smoke?” he said. “That doesn’t mean tomorrow you’re going to stop. We still ask every time and have a discussion, because it moves people along toward making a move.”

The stigma of mental illness, though still a factor, is decreasing, and families are more willing to seek help, said Dr. Steven Schlozman, a child psychiatrist and associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital. That means demand for treatment is rising. Massachusetts, like much of the country, has too few pediatric specialists to keep up.

“Most of the child psychiatrists I know are kind of drowning,” Schlozman said. “We love our work, but it’s very hard to tell patients that we can’t see them because we don’t have time.”

Schlozman said better training for primary care physicians, to make them more comfortable in dealing with more routine behavioral health problems in their offices, could help.

Schlozman said that payment for behavioral health care is often a more onerous process and requires more paperwork for families and doctors — despite state and federal rules meant to guarantee equal coverage for physical and mental illnesses. That can deter would-be child psychiatrists from the field and frustrate families, he said.

Even if a family makes an appointment with a specialist, there is no guarantee they will keep it, said Dr. Greg Hagan, interim chief of pediatrics at Cambridge Health Alliance. Problems with transportation, language barriers, reluctance, or scheduling conflicts might get in the way.

Hagan has joined a growing trend of primary care doctors who share office space with mental health professionals, to make it easier for families to see specialists. It’s not just about the convenience of being located in the same place, he said. Families often trust their pediatricians. The fact that he can call on mental health experts while the family is in the room with him helps everyone.

“We have to change the model of how families are asked to engage with the mental health system,” he said.

Schlozman said addressing early signs of mental illness or developmental disorders is crucial. The brain goes through a dramatic period of development during early adolescence. “If the brain gets sick during that time, an awful lot of bad things can get set into motion,” he said.

“These kids are our future, so what gets in the way of our taking huge steps as a nation in taking care of them?” he said. “I don’t know the answer to that.”

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Primary care doctors use several different checklists, such as the one below, to screen children for mental illness or developmental disorders. This screening tool is not designed to make a diagnosis but rather to point physicians, nurses, and families to problems that should be addressed.

Indicate whether your child never, sometimes, or often:

ªComplains of aches or pains

ªSpends more time alone

ªTires easily or has little energy

ªIs fidgety or unable to sit still

ªHas trouble with a teacher

ªIs less interested in school

ªActs as if driven by a motor

ªDaydreams too much

ªIs distracted easily

ªIs afraid of new situations

ªFeels sad or unhappy

ªIs irritable or angry

ªFeels hopeless

ªHas trouble concentrating

ªIs less interested in friends

ªFights with others

ªIs absent from school

ªIs dropping in school grades

ªIs down on him- or herself

ªVisits doctor with doctor finding nothing wrong

ªHas trouble sleeping

ªWorries a lot

ªWants to be with you more than before

ªFeels he or she is bad

ªTakes unnecessary risks

ªGets hurt frequently

ªSeems to be having less fun

ªActs younger than children his or her age

ªDoes not listen to rules

ªDoes not show feelings

ªDoes not understand other people’s feelings

ªTeases others

ªBlames others for his or her troubles

ªTakes things that do not belong to him or her

ªRefuses to share

Source: Massachusetts General Hospital

Chelsea Conaboy can be reached at chelsea.conaboy@globe.com. Follow her on Twitter @cconaboy.
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