The Demons of Childhood
Young brains break. Then comes the broken care system
Pediatricians and family practitioners prescribe over 85 percent of the psychiatric drugs today and, according to the surgeon general's report, two thirds of mental health visits are to primary-care physicians. "Clearly, half the patients I see have some kind of serious emotional problem," says pediatrician David Kaplan, chief of adolescent medicine at Children's Hospital in Denver. "Over the last five years I have been prescribing and managing more and more kids on psychotropic medication. It's a huge change in practice for us in adolescent medicine."
And not for the better. Kaplan and other pediatricians point out that the combination of more difficult cases and few available child psychiatrists leads them to dole out medicine they are neither trained in nor comfortable with prescribing. Some pediatricians, like Kaplan, who are affiliated with large hospitals or academic institutions, can consult with the child psychiatrist down the hall when confronted with a vexing case. But most don't have that luxury.
Before grim experience teaches them otherwise, desperate parents of mentally ill children assume that mental health services, like those for physical ailments, will proceed through some relatively predictable steps. The pediatrician refers you to a specialist, you get an appointment within a few weeks, the child is examined, medication is prescribed or a procedure is scheduled, and everything is reimbursed by insurance.
This model goes terribly wrong from the start. According to the American Academy of Child and Adolescent Psychiatry, there is a "crisis in the workforce." Only 6,300 child psychiatrists practice nationally, whereas, according to the Council on Graduate Medical Education, the nation needs more than 30,000 to serve those in need. Also, more than 20 percent of child and adolescent psychiatry residency programs were unfilled in 1999, and the number of child and adolescent psychiatry residents did not increase at all in the '90s. One problem is that to become a child psychiatrist, a young doctor must complete a three-year residency in adult psychiatry plus an additional two-year fellowship in child psychiatry. At the end of all that education, child psychiatrists typically end up on the bottom of the pay scale compared with other specialists.
The result is a massive maldistribution of services, with especially limited options for troubled children in rural or low-income areas. For example, there is less than 1 child psychiatrist per 100,000 young people in Mississippi, while there are nearly 20 per 100,000 in Massachusetts. Nebraska reported this year that it has barely enough mental health specialists to help children who are suicidal or in crisis.
Even if there is access to a mental health provider, there is the other problem of paying for the care. Although almost half of all children have some sort of private insurance coverage, the vast majority of those with psychiatric disorders are covered only by specialized "behavioral health carve-outs." What this means is that insurance companies have split off mental health care from primary care. Rather than a physician simply authorizing services, a "reviewer" or "gatekeeper" working for the insurance company determines what care will be reimbursed, in effect determining both the quality and the nature of the care. A recent Rand Health Program study showed that eliminating gatekeepers would most likely not raise costs for HMOs, but insurers have lobbied hard against equal treatment for mental disorders.