Chris and John are two boys who are similar to each other in many ways. They are the same age, IQ, race, and socioeconomic status. They both have loving, supportive parents and live in a safe home in a suburban neighborhood. They love to play soccer and hang out with their friends. The also both have Major Depressive Disorder, something they share in common with an estimated 12.8% of 12 to 17 year olds and 2.1% of children age 3 to 17 years old1. The key difference between Chris and John is that they go to different schools with different policies for screening for mental health problems in their students.
At Chris’ school, the children are screened for mental health problems just as they are for tested for problems with their vision and hearing. When potential problems are discovered in a student their parents are notified, offered support, and provided with recommendations for places for treatment. John’s school provides no such screening and support for mental health problems in students. As a result, Chris’ depression is discovered and treated early while John’s continues to develop unchecked. For John, the consequences of untreated mental health problems could alter the course of the rest of his life; they include difficulties with employment, dropping out of school, self-harm or suicide, substance abuse, and ending up in the criminal justice system2. The support and early treatment provided to Chris provide him with some protection from these risks.
Chris and John provide a snapshot of why policy to promote the screening and early intervention for mental health problems in children is so important. They represent the nearly 1 in 5 children in our nation who have a mental disorder3. Chris represents the 22% of children with depression who receive consistent treatment while John is among the 64% of children who receive no treatment for their depression2. While screening for mental disorders in schools and in pediatricians offices will not completely fix this problem it would go a long way in catching these cases early so that early treatment and support is a possibility.
Current bills and law that addresses this issue includes:
- The Mental Health in Schools Act (H.R. 1211/S. 1588): Would provide funding to schools promote addressing mental health issues in students including screening, support, and linking students to resources in the community4.
- Student Support Act (H.R. 2375): To provide schools with further funding to schools for hiring mental health providers and support services for addressing mental health issues in students5.
- Early and Periodic Screening, Diagnosis, and Treatment: Requires that pediatricians screen children eligible for Medicaid for conditions including mental disorders. This is a federal law however not all states strictly enforce compliance6.
It is important for healthcare providers to be aware of current legislation and policy that impacts the early screening and treatment of mental disorders in children on both the state and national level. It is our duty to act on behalf of children to promote policy that clearly addresses this issue and advocate for such policy to be consistently enforced. As providers we know the necessity of taking a mind and body approach to providing care for our clients; we should not accept the neglect of the mind in early screening and care of children.
1Perou, R., Bitsko, R.H., Blumberg, S.J., Pastor, P., Ghandour, R.M., Gfroerer, J.C., Hedden, S.L., Crosby, A.E., Visser, S.N., Schieve, L.A., Parks, S.E., Hall, J.E., Brody, D., Simile, C.M., Thompson, W.W., Baio, J., Avenevoli, S., Kogan, M.D., & Huang, L.N. (2013). Mental health surveillance among children – United States, 2005—2011. MMWR Supplements, 62(2), 1-35.
2Mental Health America (2016.). Position statement 41: Early identification of mental health issues in young people. Retrieved from http://www.mentalhealthamerica.net/positions/early-identification
3Centers for Disease Control and Prevention (2016). Children’s mental health basics. Retrieved from https://www.cdc.gov/childrensmentalhealth/basics.html
4Napolitano, G.F. (n.d.). Fact on the Mental Health in Schools Act. Retrieved from https://napolitano.house.gov/resources/additional-resources/mental-health-schools-act/facts-mental-health-schools-act
5Congress.gov (2016). H.R. 2375 – Student Support Act. Retrieved from https://www.congress.gov/bill/114th-congress/house-bill/2375?q=%7B%22search%22%3A%5B%22%5C%22hr2375%5C%22%22%5D%7D&resultIndex=1
6National Alliance on Mental Illness (n.d.). Mental health screening. Retrieved from http://www.nami.org/Learn-More/Public-Policy/Mental-Health-Screening
Child Mental Health Policy 
Great blog post (I especially loved your introduction with the two boys), and very interesting policy issue! As you stated, early intervention can greatly influence the outcome of a mental illness and, in the case of Major Depressive Disorder, can significantly reduce the frequency and severity of future depressive episodes (Cepeda, 2010). Mental health screening could very well be an easy, economical, and efficacious method of identifying depressive disorders in school-aged children. In your blog post you wrote that pediatricians are required to conduct mental health screenings for children with Medicaid, but that these screenings (and their actual implementation), vary from state to state. This is concurrent with what I read while researching the Affordable Care Act. The Affordable Care Act resulted in the largest expansion of mental health and substance abuse services to date (U.S., 2016), and it utilizes Medicaid and Medicare as its reimbursement entities. Through the Affordable Care Act, insurance companies are now mandated to offer and reimburse mental health, substance use, rehabilitative, habilitative, and preventative screening services (Centers, 2015). However, even though Medicaid must adhere to regulations set forth by the Affordable Care Act, the program remains, overall, state-based. Thus, each state can choose how, when, and where to conduct their pediatric mental health screenings. I’m looking forward to reading your blog and learning about any future changes to the system/policy which might advocate mental health screenings in school-aged children.
References
Centers for Medicare & Medicaid Services. (2015). The mental health parity and addiction equity act. CMS.gov. Retrieved from https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet.html
Cepeda, C. (2010). Clinical Manual for the Psychiatric Interview of Children and Adolescents. Washington, DC: American Psychiatric Press.
U.S. Department of Health and Human Services. (2016). Health insurance and mental health services. MentalHealth.gov. Retrieved from https://www.mentalhealth.gov/get-help/health-insurance
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Our hearts are in the same place! My approach to this issue has been to increase the integration of mental health services in primary care, but the approach to increase screening in schools is brilliant. The impact of undetected and untreated early onset mood disorders can truly have devastating effects, such as poor school performance, early sexual activity, drug and alcohol use, and higher emergency department utilization (1). What a powerful attestation of the potential benefit to improving our mental health care! In terms of policy development, there are big numbers in terms of costs associated with poor mental health. In 2010, depression alone was considered the second leading cause of years lived with a disability worldwide (2).
As you explore this issue, I urge you to consider some of the very real issues that I have come across in my DNP journey of attempting to better address mental healthcare in the pediatric population. For some parents and adolescents, there is complete resistance to any further investigation of diagnosis or possible treatment plan for mental illnesses. There is certainly stigma associated with this. Some parents are fully convinced that “my child is NOT depressed and nothing is wrong with them”, despite very real issues or concerning reports of symptomology consistent with depression or anxiety. In addition, certainly explore the issues of family involvement once a positive screening occurs and, most importantly, confidentiality for the adolescent or child that does not want their parent to know that they are struggling with their mental health.
As we increase screening and mental health services, we also must look at the funding and reimbursement for mental health services. As I looked at the bill H.R. 2375 that you mentioned, it was exciting to see the possible increase in funding for schools to increase resources (3). It also left me a bit overwhelmed FOR those workers, as those ratios seem like they would still be exhausting for the social workers and psychologists (3). Nonetheless, if we can take effective baby steps towards major change in policy surrounding improving mental health care, we can accomplish change. As I am sure you are, I am curious about the changes that could come about for mental health reimbursement and funding if the ACA is repealed in the very near future.
(1) Burnett-Zeigler, I., Walton, M. A., Ilgen, M., Barry, K. L., Chermack, S. T., Zucker, R. A., . . . Blow, F. C. (2012). Prevalence and correlates of mental health problems and treatment among adolescents seen in primary care. Journal of Adolescent Health, 50(6), 559-564. doi:10.1016/j.jadohealth.2011.10.005
(2) Ferrari, A. J., Charlson, F. J., Norman, R. E., Patten, S. B., Freedman, G., Murray, C. J. L.. . Whiteford, H. A. (2013). Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Medicine, 10(11), e1001547. doi:10.1371/journal.pmed.1001547
(3) Congress.gov (2016). H.R. 2375 – Student Support Act. Retrieved January 20, 2017, from https://www.congress.gov/bill/114th-congress/house-bill/2375?q=%7B%22search%22%3A%5B%22%5C%22hr2375%5C%22%22%5D%7D&resultIndex=1
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Screening is a very efficient way of tackling this issue and doing it within the school system is right on the money, I think. It got me thinking though, how can this be made a realistic expectation and who will be qualified to complete these screenings. The current bills are very promising, especially The Mental Health in Schools Act. It will be interesting to see how the money is distributed and what the resources will be. If the goal is to improve screening within schools, I wonder who will be responsible for preforming the screenings; social worker, school nurse or maybe even the special education teachers? In nursing school, I remember learning that a large number of the school nurses were LPN’s, with the occasional Registered Nurse. I couldn’t find any super recent information, but a 2009 report by The Arizona Health Care Workforce: Nurses, Pharmacists, & Physician Assistants by the Center for Health Information & Research April reported Full-time equivalent active LPN’s by employment were 85.7% in the school health setting.I bring this up because I wonder about the Scope of Practice, or rather comfort level of who will be preforming the screenings and if the funding will be used within the nurse setting or rather the case management or social worker side of things. When thinking about rallying for your cause, what professional venue is also as passionate? Arizona has a School Nurses Organization of Arizona that is boarded by all RN’s which may be a great resource to learn more about what’s the current process now and how they see the current policies. The next Seminar for them is actually in my own little city, July 14-16 at the Wigwam Resort in Litchfield. For information, you can go to snoa.org, I may try to attend that as well. I am very interested in this topic and look forward to see what else is happening!
Center for Health Information & Research. (2009). The Arizona Health Care Workforce:Nurses, Pharmacists & Physician Assistants. ASU Biomedicine. Phoenix: Arizona Hospital and Healthcare Assiciation.
http://www.snoa.org/index.php
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You’ve given me a lot to think about here, thank you. That’s a very good point about many schools using LPNs instead of RNs. Additionally, some districts will have schools share a school nurse; I can’t even picture how that would work. With school nurses being stretched that thin it would certainly add to the burden. One solution might be to a school psychologist, even if they had to be shared between a few schools. Thank you for the info on the SNOA.
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I love everyone’s feedback and would add that the despairity between perceptions from parents regarding how depressed children are and how depressed kids actually are is remarkable. I think that could be addressed with educating parents. What better “screener” than someone who is with them 16hrs a day or so.
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I think educating parents is absolutely important in this endeavor especially when it comes to addressing parent perceptions. As a source of screening we know parents usually provide valuable insights. However, the school environment brings out symptoms that might not be observed at home.
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