Improving Children’s Mental Health

By Kristine Goodwin and Jennifer B. Saunders | Vol . 22, No. 2 / January 2014

NCSL NewsDid you know?

  • Mental disorders affect as many as 20 percent of U.S. children, but just 21 percent of affected children receive treatment.
  • Childhood mental disorders can be effectively treated and managed, especially when they are diagnosed and treated early.
  • The annual cost of mental disorders in those under age 24 totals $247 billion—which includes the costs of health care, special education and juvenile justice services and decreased productivity – making it one of the most costly childhood conditions.

Mental health conditions among children are under-treated and on the rise, according to a 2013 Centers for Disease Control and Prevention (CDC) report. One in five children experiences a diagnosable mental health disorder (such as depression, anxiety, attention deficit/hyperactivity disorder, autism or Tourette syndrome), but only 21 percent of diagnosed children receive needed treatment.

Mental disorders burden individuals, families, schools and communities. Elementary school children with mental disorders are more likely to miss school and are three times more likely to be suspended or expelled than their peers. Approximately 50 percent of affected high school students drop out of school. Children with one mental disorder often experience other mental disorders or chronic medical conditions, and they have an increased risk of mental disorders continuing into adulthood, which can have life-long negative effects on quality of life, physical health, relationships and productivity.

State Action

States have adopted several approaches to expand coverage for treatment, develop workforce capacity, integrate mental health and primary care services, identify problems early and fund mental health services.

Expanding Coverage. Medicaid finances 27 percent of mental health services for children and adults. Medicaid’s benefit package for children—known as Early, Periodic, Screening, Diagnostic and Treatment (EPSDT)—requires coverage for all medically necessary treatment, including mental health services. Several states, including Colorado, Connecticut, Massachusetts and North Carolina, have adopted strategies to promote screening during primary care visits for children who are enrolled in Medicaid.

States have enacted legislation to strengthen mental health benefits in private health insurance policies as well. Louisiana requires insurers to maintain mental health and substance abuse providers in their networks, and Maryland requires plans to inform policyholders about mental health and substance abuse benefits. Many states have adopted some form of mental health parity to require equal coverage for physical and mental health conditions.

Developing Workforce Capacity. States grapple with workforce shortages among primary care providers, child and adolescent psychiatrists, and other mental health providers. According to the U.S. Health Resources and Services Administration, almost 91 million Americans lived in one of the 3,669 Mental Health Shortage Areas in 2012; an estimated 1,846 psychiatrists and 5,931 other providers are needed to meet needs in these areas. Strategies to expand workforce capacity include loan repayment programs; tele-health (providing care remotely); enhanced residency training; and using other qualified health professionals, such as social workers and mental health and substance abuse counselors.

Integrating Mental Health and Primary Care. Integrating behavioral health and primary medical care can identify problems and initiate treatment earlier—e.g., in a well-child visit—and coordinate care among providers. States with Medicaid-managed care programs promote integration in various ways, such as by establishing health homes to increase care coordination among providers and reimbursing primary care providers for behavioral health screenings. In 2008, the Missouri legislature allocated $1.4 million to support a three-year Behavioral Health and Primary Care Integration pilot program to promote integration between federally qualified health centers and community mental health centers. Some states have adopted strategies to coordinate mental health and primary care services among state agencies. In 2013, the Wisconsin Legislature created the Office of Children’s Mental Health Services to coordinate initiatives and improve integration across state agencies.

Early Identification and Intervention. Some states have enacted legislation to promote early identification of and intervention for mental health problems among children. Primary care providers are well-positioned to identify concerns and partner with mental health specialists to ensure that children receive appropriate treatment. In addition, in 2013, several states—including Arkansas, Connecticut, Minnesota, Texas and Washington—enacted policies to provide certain school personnel with mental health training and services. In West Virginia, school-located mental health services are an entry point for many other services and provide a “foundational strategy” for promoting mental health, according to a 2013 Center for Health and Health Care in Schools report.

Funding Mental Health. Reversing a downward trend, the National Alliance on Mental Illness (NAMI) found that 37 states increased state general fund allocations for mental health, and another eight maintained levels for fiscal year 2014 standards.

Federal Action

The Affordable Care Act (ACA) funds numerous approaches to strengthen children’s mental health, including provider loan repayment programs and other workforce development strategies, health center expansion to improve access for underserved populations, voluntary early childhood home visiting services to identify problems early and connect families to resources, and integrated care models such as health homes. It also expands federal mental health parity requirements to certain plans and requires coverage of specific mental health services.

Among numerous other federal programs that support children’s mental health are the Maternal and Child Health Services Block Grant (Title V), Supplemental Social Security Income, and the Individuals with Disabilities Education Act (IDEA).

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