The American Academy of Pediatrics is leading a coalition of eight provider and family groups, including APA, in making a public statement that managed-care practices are having a devastating effect on children's mental health and substance-abuse services.

The coalition's primary recommendation is demanding that parity be established between medical health services and mental/behavioral health and substance-abuse services.

Its statement, issued in September, asserts that attempts to restrain costs have decreased the availability of children's mental health services to the point that without the public and private commitment to increase resources, "current and future needs will not be met."

Michael C. Roberts, PhD, an APA representative to the coalition, said that the impressive agreement among the groups on the nature and the vast extent of the problem transcended "disciplines, reimbursement issues, power differentials and turf problems."

In addition to APA and the American Academy of Pediatrics (AAP), the other coalition members are the Academy of Eating Disorders, American Academy of Child and Adolescent Psychiatry, Family Voices, International Society of Psychiatric­Mental Health Nurses and the Society of Developmental and Behavioral Pediatrics. The document was also endorsed by the National Association of Pediatric Nurse Associates and Practitioners, the National Association of Psychiatric Health Systems and the National Association of School Psychologists.

Obstacles to care

The decline in children's services, says the group, "is due to benefits packages that provide limited mental health services or carve out plans, in which behavioral health care may be 'carved out,' or not included and contracted separately, making mental health services more difficult to obtain."

To further exacerbate matters, says the statement, this decline in services is happening at a time when primary care is identifying 7 percent to 18 percent more psychosocial problems in children than two decades ago--and when there's increasing evidence of the effectiveness of specific mental health and substance abuse services.

"The low number of qualified child mental health and substance-abuse clinicians contracting with behavioral health management further limits access," says the statement.

The obstacles to increasing those numbers, the group says, include the difficulties mental health clinicians have in getting credentials in multiple insurance panels, and--when they are on the panels--facing inadequate payment, problems in obtaining approval for services and burdensome administrative practices.

"These factors result in a decrease in available facilities and a disincentive for professionals and those in training to enter or remain in the field," says the group.

In addition, the document says, primary-care physicians themselves don't receive adequate reimbursement for addressing psychosocial problems, they have less time to develop relations with families and are less likely to identify mental health and substance-abuse problems.


Beyond its recommendation for parity for mental health care, the coalition called for providing more resources for the State Children's Health Insurance Program, and increasing support for training and job incentives for child mental health and substance-abuse clinicians.

To counter the absence of coordination among the health care, schools, social services, justice system and other sectors dealing with children, the document also recommends the development of better communications and referral networks that work no matter where a child presents with problems. It also calls for compensating clinicians for case management and coordination of care through, for example, reimbursement for the counseling and consultation CPT codes.

Elaine Holland, assistant director in the AAP department of federal affairs, says that the document's strength lies in its being the consensus of a range of groups. She says AAP and the other coalition groups likely will use the statement in future advocacy with the federal government, the states, the insurers and others.

She indicates that pediatricians initiated the statement's development because, "They have to deal with children's mental services regularly and they run into all kinds of barriers or lack of services."

Mark Wolraich, MD, chair of AAP's Committee on Psychosocial Aspects of Child and Family Health, says that under the current restraints on pediatricians, "Time just does not allow for much preventive care, including work with psychosocial problems."

And yet, he says, for the next century, dealing with such problems will become a much more significant part of pediatric practice.

"We have done a good job of preventing or controlling many of the diseases that used to be problems with children," he adds. "So the focus of care becomes much more quality of life, rather than life-and-death situations. And that is where the pediatrician becomes involves in psychosocial aspects, both in terms of primary care and referrals."

Daniel Armstrong, PhD, another APA representative to the coalition as well as to the AAP psychosocial committee, noted that the committee will meet this month and discuss future action on the statement, including possible political efforts.

In the meantime, Armstrong, noting APA's "major involvement in establishing the parameters of this statement," says that the process has highlighted the benefits of professional collaboration among psychology, pediatrics and other professional groups, a linkage he says can only serve to help children.

Further Reading

The statement, "Insurance Coverage of Mental Health and Substance Abuse Services for Children and Adolescents," is on the AAP Web page: www.aap.org.