ChineseEd. Note: Even though access to mental health coverage has increased under the Affordable Care Act, California families looking for mental health services for their children frequently encounter a dysfunctional system. NAM spoke with Patrick Gardner, the founder and president of the San Francisco-based Young Minds Advocacy Project, which conducts legal advocacy for low-income children and families around access to mental health services. Gardner is an attorney specializing in children’s mental health policy. What should we be doing to get kids in California the mental health services they need?
California’s spending on Medi-Cal per person is very low compared to other states. Some take pride in that and others suggest that it creates an enormous challenge in assuring that there are sufficient resources and access to care. My understanding from speaking with providers is that all across the state right now, there are waiting lists for children’s access to mental health services. It’s one of those secrets that nobody likes to talk about … the fact that it’s going to get worse.Why is it going to get worse?
Because of the change in the federal reimbursement rate [for Medi-Cal], and the 10 percent cut from the state [approved in 2011 during California’s budget crisis]. I think lots of organizations believe that they lose money on Medi-Cal clients. And if that’s accurate, then over time you’re going to see a disinvestment in services and service capacity for kids. Are there any groups of kids that are particularly impacted by lack of access to care?
One thing that’s been a longstanding problem is the issue of when you move a child who’s in foster care out of the county where they entered care – they have a much more difficult time accessing mental health services. Children involved with the child welfare and juvenile justice systems have a disproportionately high demand for mental health services, and so making it more difficult for those kids to get treatment is a real problem.How many kids are we talking about?
About one in five foster children in the state of California are moved out of the county in which they entered care, or around 12,000 children statewide. We’re talking about thousands of children who are denied services or provided services late or with insufficient intensity to meet their needs. We’ve had promises [from the state] for years now and seen no progress ... It’s a fixable problem. What are other problems you see in the way we provide mental health care to children?
There’s a considerable amount of evidence to suggest that a lot of the interventions that we fund and provide to young people are not especially effective. It’s not enough to talk about how much money is spent … There is an awful lot of practice that is undertaken that doesn’t result in some measurable improvement. What’s an example of this?
If you look at the approach of office therapy, where you’re doing a 50-minute talking session with a child with serious mental health needs – the science tells us that’s not an evidence-based practice for children. It’s a technique that was adopted from adult practice and applied to children. Sitting down and having a conversation with a child about their thoughts and feelings for 50 minutes, is that going to improve their behavior days or weeks later? I think a lot of parents would say no, not really. That doesn’t mean that it is never valuable, but what’s needed – particularly for children with serious emotional disorders – is a much more intensive intervention, somebody in the home to demonstrate how to de-escalate a child who is losing control, for example. What can we expect legislatively around children’s mental health in the coming year?
I think there is going to be a push to try to implement mobile crisis services, which involves bringing a mental health team to the home, school, or other place where the child is in distress and stabilizing him or her on site. When done well, the mobile crisis team includes someone from the child’s own treatment team… That has been demonstrated to be a much better approach because it typically means you can avoid hospitalizing the child, which is very expensive and often not effective. What kinds of changes could improve the system as a whole?
The thing about children is that they live in families and they are served by multiple agencies. You have schools, you have foster care, you have juvenile justice, you have the mental health care system… So in order to be effective in delivering mental health services, it has to be done in a coordinated way, and that’s a really challenging thing to do. Under the best circumstances you want the different systems to work together collaboratively... so that they identify children together, so that they organize their planning and interventions together, and ultimately so they measure and evaluate their effectiveness together so that over time the child gets better.What are some of the positive developments you’ve seen in children’s mental health care?
In the past decade or so, there has been a groundswell of developing promising practices and evidence-based mental health care for young people … We are also increasing access to health insurance such that few children should not be able to access mental healthcare. Additionally, substantial efforts are being made to de-stigmatize mental illness and mental health needs, making the linking of young people in need with effective services easier. Finally, the tools and technology to measure and assess our efforts and accomplishments are readily available. Our job now is to organize mental health stakeholders to pull these promising threads together into a coordinated system of care that provides high quality, effective mental health care to every child in need.