When parents are worried about a child being depressed or having an eating disorder or a problem with drugs or drinking, the family pediatrician is the natural place to turn for help. But families might not get the help they need. Doctors, it turns out, are often reluctant to tackle children's mental and behavioral problems.
That's the sobering news from a study that offers clues as to why so many families struggle to get treatment for their troubled children. Fortunately, it also offers insight into how parents can work the system to get their children the help they need.
Mental-health care may sound like a frill compared with, say, treating asthma or strep throat. Yet mental-health problems are nearly twice as common as asthma, with at least 11 percent of children having a mental or behavioral disorder that significantly impairs their life. Given that, you'd think that pediatricians would be all over the mental-health issue.
Not so, alas. Doctors, like the rest of us, are uncomfortable bringing up subjects that carry a stigma, as mental illness still does. Another big problem: Pediatricians, like all primary-care docs, have way too much on their plates and, thanks to measly insurance reimbursements, way too little time for each patient. In 2006, researchers tallied up all the pieces of advice that the American Academy of Pediatrics expects its members to convey to parents and patients. The grand total: 162. Given that most kids see the pediatrician just once or twice a year for a brief office visit, that to-do list is absurd. Doctors are left to choose one or two items to address, and the odds are their choice won't match the top concerns of parent or child.
That's especially true with mental health, which accounts for just a small fraction of those 162 items. "The majority of pediatricians are not comfortable treating these conditions," says Ruth Stein, a professor of pediatrics at the Albert Einstein College of Medicine and the Children's Hospital at Montefiore in the Bronx, N.Y. Stein looked at responses from a 2004 survey of pediatricians across the United States and reported in the January Ambulatory Pediatrics. Almost all of the 659 pediatricians who responded said they should be responsible for identifying mental and behavioral problems in children. The numbers get interesting when the docs were asked who should manage or treat the problems. Seventy percent were willing to take on treating ADHD, but the numbers plummeted for other disorders: Just 25 percent were willing to treat depression, for instance; 21 percent were ready to tackle substance abuse; and 32 percent would treat or manage eating disorders. Most of the doctors said they would refer children with those diagnoses for treatment elsewhere.
Good idea, except that it's exceedingly difficult for families to find mental health services. There are about 6,300 child psychiatrists nationally, while more than 30,000 are needed to meet the need, according to the Council on Graduate Medical Education. Those parents who do manage to find services often struggle to get insurers to pay for the intensive treatment needed for problems like eating disorders. (For more information on insurance and mental-health care, see "Paying a High Price for Mental Health.") So, for most families, primary-care doctors, including pediatricians, are the only option. The trick, then, lies in figuring out how to work with an overburdened doctor who really does want to take good care of each child.
There's an interesting clue in Stein's survey: Seventy percent of pediatricians put treatment of ADHD on their "to do" list. That may well be because over the past five years the American Academy of Pediatrics has put considerable effort into educating its members on how to treat ADHD themselves. In addition, doctors know that pharmaceutical treatments for ADHD such as Ritalin are relatively safe and widely accepted. "The treatment involves tools that are very comfortable for the pediatrician," says Stein. The key tool? "Writing prescriptions."
This doesn't mean that parents have to let the problems of modern pediatric practice define their children's healthcare. Or, as Stein puts it: "A pediatrician comes with his or her agenda, with what he or she thinks should be done. That shouldn't crowd out the parents' concerns." It's statements like that that give me the gumption to go to the doctor's with my own to-do list and to make sure that it's my family's concerns that drive the agenda for those 10-minute visits, not just the doctor's.
That probably won't be as scary as it sounds. One big positive in this latest survey is that pediatricians do know that it's their responsibility to care for the whole child. Their heads, and their hearts, are in the right place. But both doctors and parents have to work to tailor healthcare to the needs of each child, in an era when doctors are given neither the time nor the money to do so on their own.
"The Demons of Childhood," a 2002 U.S. News & World Report special report, explored why it can be so hard to get mental-health care for children.