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America Unkind to Mentally Ill Children, Reports Argue

The Washington Post

America’s emotionally disturbed children are under-recognized, under-diagnosed and under-served. What is more, the field is under-researched, vastly under-funded and, psychologist Alan E. Kazdin said, “there are a whole lot of other ‘unders’ about the situation.”

In two reports issued last month and half a dozen other studies--some published, some not--scientists, activists and some members of Congress made the point that, as Sen. Christopher J. Dodd (D-Conn.) put it: “America is not kind to her children who have mental and emotional problems.”

Dodd spoke at a news conference heralding the release of a report from the National Mental Health Assn. spelling out the failure of public agencies to meet the needs of disturbed youngsters.

Kazdin, professor of child psychiatry and psychology at the University of Pittsburgh School of Medicine and the Western Psychiatric Institute, made his comments at a briefing for reporters on the contents of a report by the Institute of Medicine of the National Academy of Sciences.

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About 12% of the U.S. population under the age of 18--or 7.5 million children and teen-agers--"have a diagnosable mental disorder,” according to child psychiatrist James F. Leckman of the Yale University Child Study Center, chairman of the Institute of Medicine’s committee that compiled the report, “Research on Children and Adolescents With Mental, Behavioral and Developmental Disorders.” Other estimates put the number as high as 11 million to 14 million children.

Although the report cited significant progress in identifying and treating many of the problems, only about 2.5 million receive treatment, one-third of those who need it, the report said.

The report, prepared at the request of the National Institute of Mental Health, urged a four-fold increase in research funds over a five-year period, aimed at sorting out the disorders that afflict young people and finding the best approaches to their treatment. Leckman, in an opening statement, warned that “there are fewer than 100 child psychiatrists who devote 30% or more of their time to research” and that the figures are “equally dismal in psychology, pediatrics, social work and special education.”

He cited lack of support for such research in professional schools and universities and among local, state and federal agencies and suggested that this was caused by “the stigma associated with mental illness, the relatively low status accorded those who work with children and a failure on the part of many policy makers to recognize that these research dollars are an investment in the future.”

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Leckman and other members of the Institute of Medicine panel and staff noted that there had been tremendous strides made in diagnosis and treatment of mental illness in children, but not nearly enough.

Diagnoses Often Missed

Frederic Solomon, a psychiatrist who heads the institute’s Division of Mental Health and Behavioral Medicine, said diagnoses are often missed. He cited a forthcoming study conducted in a large health-maintenance organization in which a group of children were examined both by pediatricians and mental-health specialists. The psychiatric researchers found that fully 20% of the youngsters were “discernibly, diagnosably disturbed and in need of further evaluation.” The pediatricians found only 5%.

“This is just a fact of life, this under-recognition of the extent of the problem,” Solomon said. “For children who externalize their emotional disturbance--letting it out, as it were--the problem may be mistaken as misbehaving. But for those who keep it inside, the problem may be overlooked and they may even become suicidal.”

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Equally disturbing, the Mental Health Assn.'s report on “invisible children” suggests that many who do receive treatment are treated inappropriately.

Ann Ince, who coordinated the volunteers who did the basic surveying for the Mental Health Assn.'s report, cited this quote from a recent Child Welfare League of America Colloquial:

Invisible Children

“If you are an adolescent and black and you are seriously emotionally disturbed, the chances are that you will end up in the justice system, rather than in a treatment setting. If you are a Native American child and you are seriously emotionally disturbed, you will likely go without treatment or be removed legally and geographically from your family and tribe. If you are a child who is Hispanic and seriously emotionally disturbed, the assessment is not going to be in your own language. If you are an Asian child and seriously emotionally disturbed, you will probably never come to the attention of the health-care system.”

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The invisible children project “truly documents” that statement, Ince said.

The project was basically a survey by National Mental Health Assn. members taken in their own states. Project directors received responses from all 50 states and complete information from 36. The survey covered children and adolescents placed by public agencies in state hospitals or referred to out-of-state psychiatric residential programs. It found that:

- More than 4,000 children (defined as those who are under age 18) were sent to out-of-state treatment at a cost of $215 million.

- In 1986, more than 22,000 children were placed in state hospitals at a cost of close to $300 per day per child--or a total of more than $850 million.

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- Few states had community- and family-based programs, which have been shown to be most effective in treatment of many of the emotional problems of young people. Ince quoted a colleague who noted that “children and families have access to either outpatient counseling or inpatient hospitalization, a situation analogous to a patient with heart disease having access to only an aspirin or a transplant.”

The mental health association, which dealt only with public agencies, also found that some states had no information on the whereabouts of their disturbed children, and that 91% of the out-of-state placements were made by “state agencies other than the mental-health authority.”

Rep. George Miller (D-Martinez) chairman of the House Select Committee on Children, Youth and Families, noted in a statement issued to accompany the report: “It costs states over $52,000 a year to treat one child in an out-of-state facility and over $38,000 for about four months in a state hospital, as opposed to $15,000 to $18,000 a year for day treatment and only $1,100 for intensive in-home crisis service.”

As a result of hearings held last year by Miller’s committee, 10% of federal block grants to states for treating alcohol and drug abuse and mental illness has been set aside for community-based care for severely emotionally disturbed children and adolescents. But, he said, “it’s easier for administrators to send a kid off to someone else to worry about than to develop alternatives--easier to rely on insurance policies, which favor the most restrictive, costly and disruptive types of care.”

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Ira Schwartz of the University of Michigan School of Social Work Center for the Study of Youth Policy has just completed a study of about 27,000 children in mainly short-term psychiatric units of general hospitals around the country. His survey found that two-thirds of the children were admitted for “relatively non-serious” problems, such as non-dependent use of drugs and alcohol, adolescent disturbances and minor depressions, he said.

“Probably the vast majority of these kids could be handled in a non-hospital-based setting if the appropriate outpatient services were available,” Schwartz said.

Length of Stay

He also noted that the length of stay in these units depended more on the availability of third-party insurance and the presence of a specialized psychiatric or substance-abuse-treatment unit than on the progress of the individual patient.

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Moreover, he said, “we found no evidence that inpatient is more effective than good-quality outpatient care.”

In response to the findings by Schwartz and others, the American Psychiatric Assn. issued a statement last month declaring that " . . . the decision to admit a child or adolescent should be based on medical necessity and the best interests of the patient (and where appropriate) his or her family. Financial interests of either the doctor or the hospital must never dominate these decisions.”


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