A recent study documented a large increase in prescriptions of stimulants and antidepressants among preschoolers, and has prompted public and professional concern about the effects of mood-altering drugs on young children. In response, the White House announced a broad initiative on children’s mental health, including more government money for research, new labels on drugs for pediatric use, educational materials for parents, and a fall White House conference. To place these events in their larger context, this Issue Brief summarizes the findings of the Children’s Mental Health Alliance Project, which conducted a multidisciplinary consensus conference in November 1998 followed by a year-long dialogue with clinicians, researchers, and families

Gadomski, Anne

Steinberg, Annie G

Wilson, Michele D

English

ScholarlyCommons@Penn

University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics4-18-2000Children’s Mental Health: Recommendations forResearch, Practice and PolicyAnnie G. SteinbergAnne GadomskiMichele D. WilsonFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/11For more information, please contact repository@pobox.upenn.edu.Steinberg, Annie G.; Gadomski, Anne; and Wilson, Michele D.. Children’s Mental Health: Recommendations for Research, Practiceand Policy. LDI Issue Briefs. 2000; 5 (7). http://ldi.upenn.edu/policy/issue-briefs/2000/04/18/children-s-mental-health-recommendations-for-research-practice-and-policyChildren’s Mental Health: Recommendations for Research, Practice andPolicyAbstractA recent study documented a large increase in prescriptions of stimulants and antidepressants amongpreschoolers, and has prompted public and professional concern about the effects of mood-altering drugs onyoung children. In response, the White House announced a broad initiative on children’s mental health,including more government money for research, new labels on drugs for pediatric use, educational materialsfor parents, and a fall White House conference. To place these events in their larger context, this Issue Briefsummarizes the findings of the Children’s Mental Health Alliance Project, which conducted amultidisciplinary consensus conference in November 1998 followed by a year-long dialogue with clinicians,researchers, and families.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/11Leonard Davis Institute of Health EconomicsLDI Issue BriefVolume 5, Number 7April 2000Annie G. Steinberg, MDLDI Senior Fellow, Assistant Professorof Psychiatry and Pediatrics,Co-Director, Center for Children’sPolicy, Practice and ResearchUniversity of PennsylvaniaAnne Gadomski, MD, MPHResearch Scientist, AttendingPediatrician, Bassett Research InstituteMichele D. Wilson, MDDepartment of PediatricsChildren’s Hospital of PhiladelphiaChildren’s Mental Health: Recommendationsfor Research, Practice and PolicyEditor’s Note: A recent study documented a large increase in prescriptions of stimulantsand antidepressants among preschoolers, and has prompted public and professionalconcern about the effects of mood-altering drugs on young children. In response, theWhite House announced a broad initiative on children’s mental health, including moregovernment money for research, new labels on drugs for pediatric use, educationalmaterials for parents, and a fall White House conference.  To place these events in theirlarger context, this Issue Brief summarizes the findings of the Children’s Mental HealthAlliance Project, which conducted a multidisciplinary consensus conference in November1998 followed by a year-long dialogue with clinicians, researchers, and families.The landscape for children’s mental health services has changed dramatically in the pastdecade, due to the confluence of several factors.• The “decade of the brain” has witnessed the increased use of psychotropicmedications, and  further development of biological psychiatry. Advances inpsychopharmacology have led to many breakthrough treatments, particularly in mooddisorders among adults.  Psychotropic medications are now being used in children aswell, although extrapolation of safety and efficacy data from adults is not always valid.• The emergence of managed care has shifted children’s mental health care fromspecialists to primary care providers. Community surveys indicate that in some areas,two-thirds of children with psychiatric disorders do not receive specialist care.• Epidemiological research has documented the under-recognition of mental healthproblems, and resulting unmet needs, of children in primary care.  Roughly one infive children attending pediatric practices has significant mental health problems.  It isestimated that 60% of them do not receive the services that they need.Despite a lack of data on the outcomes of treatment with many psychotropic medicinesamong children, their use in children is rising. The most common psychotropicmedications prescribed are stimulants to treat attention deficit hyperactivity disorder(ADHD), and antidepressants.• In the last 15 years, the 5-through-14-year-old age group has experienced a greatincrease in stimulant treatment for ADHD, and the 15-through-19-year-old agegroup has had sizable increases in the use of antidepressants.• Public concern has focused on the possibility that psychotropic drugs are beingoverutilized in children.  However, the level of psychotropic drug use may reflect theThe shifting landscapePsychotropic drug use inchildren grows dramaticallyactual prevalence of childhood mental disorders. According to the 1999 SurgeonGeneral’s Report on Mental Health, about 6 to 9 million children and adolescentshave “serious emotional disturbances”, accounting for 9% to 13% of all children.Alternately, the increased utilization could reflect a societal shift toward includinglearning and developmental problems within the mental health sphere.• A recent study in the Journal of the American Medical Association found that thenumber of preschoolers taking stimulants more than doubled between 1991 and1995, and the number of children on antidepressants increased 200%.  Overall, theresults suggest that 1% to 1.5% of children ages 2 to 4 years old may be takingstimulants, antidepressants, or antipsychotic medications.• Among children, 75% to 80% of psychotropic medication is prescribed off-label,meaning that its use is not officially approved by the Food and Drug Administrationfor this age group.  For example, Ritalin, a stimulant used to treat ADHD, has notbeen tested or approved for use in children below age six.• Practice patterns have outpaced the research on the effectiveness of different treatmentoptions.  There is good evidence that sustained treatment with medication providescontinued benefit for children over six with ADHD; there is far less evidencesupporting the use of medication to treat children with anxiety or mood disorders.With the proliferation of managed care organizations, primary care providers oftenfunction as gatekeepers—sometimes with disincentives to refer to mental healthspecialists.  However, the overall impact of managed care on access to and quality ofchildren’s mental health services is not clear.• Research on the impact of managed care is hampered by the rapid evolution ofmanaged care, the turnover of managed care organizations, and the lack of aconsistent database that would allow tracking of outcomes.• Mental health care carve-outs are rapidly expanding within managed care. In a typicalcarve-out program, an independent company contracts with the managed care plan toprovide mental health services, usually on a capitated basis.  Advantages of thisapproach are that providers can focus on specific conditions and offer competitivecapitated rates. The disadvantages of carve-outs are that they allow less integrationwith primary care, and exacerbate the separation between physical and mental health.Carve-outs challenge the fundamental collaborative model of care for children andfamilies.• Emerging studies on mental health carve-outs (in adults) document 30% to 40% costreductions, although apparent reductions might instead represent cost shifting toother entities (such as public agencies, primary care providers or schools).  Carve-outsgenerally save money by reducing hospitalizations, shifting inpatient to outpatientcare, and replacing psychiatrists with masters-level therapists.  However, the impacton quality of care is unknown.The current “scorecard” on mental health screening of children in primary care is notoptimistic.  The constraints of primary care practice (13 minutes allotted per visit onaverage), and the limited availability of mental health specialists, make it difficult forpediatricians and family practitioners to implement systematic screening procedures ordiagnostic assessments.• Valid screening tools exist (for example, the Pediatric Symptom Checklist), butprimary care providers often lack the information or resources necessary to act on theManaged care affects whodelivers mental healthservices to childrenPrimary care providersneed additional resourcesto identify and addresschildren’s mental healthneedsresults.  Studies show that even when psychosocial issues are elicited as part of well-child visits, primary care providers respond with information, reassurance, guidanceor referral less than half the time.• Many primary care providers express concern about making the right diagnosis,choosing the right treatment modality, and picking the right medication when facingmental health problems in children. To address identified mental health problems,primary care providers need readily available information regarding next steps,including accessible mental health referral sources and direct consultation withspecialists.• Outcomes data are needed to develop an evidence-based approach to what works inchildren’s mental health service delivery.  Such studies would help redefine whatconstitutes “best practices” in the primary care/specialist relationship as it pertains tochildren’s mental health, rather than continue to have payers and mental healthprofessional shortages determine the frequency, level, modality and provider of mentalhealth services.Many experts recognize the need for a system of care that integrates mental healthservices with other health and social services.  A systems approach can be seen as a“carve-in” to meet the needs of children and families.• “System of Care” studies show that integrated systems provide better access totreatment, greater continuity of care, and higher client satisfaction, but at higher costand with questionable improvements in outcomes. Evaluating the effectiveness ofsuch systems poses a complex and vexing challenge because it involves identifyinghard-to-measure outcomes from multiple domains.• School-based centers provide a unique opportunity to provide access to mental healthcare to children, but programs have been implemented in a piecemeal fashion.A comprehensive approach is needed to integrate these programs, and place themwithin a continuum of interventions addressing behavioral, learning, and emotionalproblems that affect development and learning.An evidence-based approach to children’s mental health problems is needed and mustaddress the complexity of working with several levels of primary care providers andspecialists.  Practice guidelines should be developed to guide the referral process andreduce variations in care.• The limited evidence about the efficacy of psychotropic drugs for children ishindering development of an evidence-based approach to care. Several researchinitiatives are underway, but other studies are needed, especially addressing theefficacy of combinations of drugs and combinations of drugs and psychotherapy.• There is limited evidence about the effectiveness of primary versus specialty care.Studying “usual care” in real-life settings is essential in translating research intopractice. Measures of function, outcome, quality, readiness for change, parental andfamily function, and systems coordination need to be developed to fully capture thecomplexity of the factors that affect children’s mental health.• Research on the cost-effectiveness of children’s mental health programs in primarycare is underdeveloped.  Studies are needed to analyze costs in terms of long-termoutcomes, impact on other systems (juvenile justice, schools, etc.) and effects on otherpopulations. Long-term studies would clarify the extent to which early mental healthinterventions prevent or reduce adult mental health problems and disability.A system of care model holdspromise for children’smental healthSetting a research agendaThis Issue Brief is based on the following monograph: A.G. Steinberg, A. Gadomski, M.D. Wilson. Children’s Mental Health: The Changing InterfaceBetween Primary and Specialty Care. Report of the Children’s Mental Health Alliance Project, Philadelphia, PA 1999. [A limited number of copies areavailable and can be obtained at no cost by contacting Annie Steinberg, MD, Children’s Seashore House of the Children’s Hospital of Philadelphia, 3405Civic Center Boulevard, Philadelphia, PA 19104.]Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104-6218,215-898-5611.Janet Weiner, MPH, Associate Director for Health Policy, EditorDavid A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and social and ethical issuesthat influence how health care is organized, financed, managed, and delivered in the United States and internationally. The LDI is a cooperative ventureamong Penn schools including Dental Medicine, Medicine, Nursing and Wharton. For additional information on this or other Issue Briefs, contact JanetWeiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).Nonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue BriefPublished by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTEDVisit us on the web at www.upenn.edu/ldi/POLICY IMPLICATIONS The Children’s Mental Health Alliance Project developed recommendations forpolicymakers to overcome the increasing fragmentation of the health care system and toaddress the burden of illness arising from unrecognized or untreated mental healthproblems in children.• Universal coverage and comprehensive mental health benefits are a necessary, thoughnot sufficient, condition for receiving appropriate treatment.  Mental health servicesfor children and adolescents should be integrated into or closely coordinated withoverall health care of children and families.• Managed care organizations, especially those serving Medicaid populations, should berequired to demonstrate coordination and a system of care.  Funding streams forchildren’s mental health issues should be united and tied to a consolidated, ratherthan categorical, system of care.• Primary care providers need increased training in the diagnosis and management ofcommon mental health problems and appropriate screening tools that fit into thedemands of busy office practices. To integrate mental health services into primarycare, guidelines should be developed that clarify the roles of primary and specialtycare providers, and guide decisions on when to refer.• A uniform approach should be taken to track quality indicators in children’s mentalhealth care.  For example, potential consumers and managers should have access toinformation regarding how a health plan identifies children with mental health needs,the average number of visits for a mental health problem, and the percentage ofchildren treated pharmacologically for a mental health concern.

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