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Building mental health and caring for vulnerable children: Increasing prevention, access, and equity

      Executive Summary

      Mental health challenges impact approximately 20% of youth, yet nearly two-thirds receive no professional treatment. The dynamics underlying this service gap are complex, involving access issues, a health system infrastructure ill-suited to serve vulnerable youth, provider shortages and broad reaching stigma that dampens help-seeking behavior. Evidence-based approaches exist but often are not implemented, particularly ones that address the complex relationship of poverty, trauma and social disparities. Research supports that children's behavioral symptoms can be decreased via early screening and treatment, family connections, school support and increasing community ties. Despite efforts to improve access to effective child services, most states continue to earn low grades on their child mental health indicators. The policy recommendations advanced here offer viable approaches to improving access to child mental health services and implementing prevention/early intervention with underserved youth.

      Background

      From 13% to 20% of children
      The term “children” is intended to represent a broad age group spanning early childhood, school-age, adolescence and young adulthood, unless there is a specific reference to the adolescent age group.
      have a diagnosable mental health problem, yet nearly two- thirds receive little or no professional help and lack access to evidence-based services (
      • Perou R.
      • Bitsko R.H.
      • Blumberg S.J.
      • Pastour P.
      • Ghandour R.M.
      • Gfroerer J.C.
      • Hedden S.L.
      • Huang L.N.
      Mental Health Surveillance among Children, United States, 2005–2011.
      ). Social disparities in economic and environmental contexts create mental health risk for all youth but especially among those who are underinsured and disproportionately from low socioeconomic racial/ethnic minority groups (
      • Alegría M.
      • Green J.G.
      • McLaughlin K.A.
      • Loder S.
      Disparities in child and adolescent mental health and mental health services in the US.
      ). For these under-served groups, health access issues are compounded by conventional service structures that often do not accept public insurance, have long wait times, and whose clinical hours do not accommodate low-wage shift positions (
      • Cummings J.R.
      • Wen H.
      • Druss B.G.
      Improving access to mental health services for youth in the United States.
      ,
      • Hodgkinson S.
      • Godoy L.
      • Beers L.S.
      • Lewin A.
      Improving mental health access for low-income children and families in the primary care setting.
      ). Thus, these children have a high prevalence of mental health issues, and their life circumstances often put them at increased risk, yet they traditionally have poor access to mental health services.
      The negative consequences of youth mental health disorders are high. Seventeen percent of high school students have seriously considered suicide, and 7.4% have attempted to take their own lives (
      • Kann L.
      • McManus T.
      • Harris W.A.
      • Shanklin S.L.
      • Flint K.H.
      • Queen B.
      • ...
      • Lim C.
      Youth Risk Behavior Surveillance-United States, 2017.
      ). Mental health disorders among children can lead to school failure, alcohol or other drug abuse, family discord, violence, and suicide (
      National Library of Medicine
      National Institutes of Health. Child and adolescent mental health.
      ). Lack of access combined with heightened risk particularly impacts the future well-being of children who live in conditions of poverty and social disadvantage (
      • Yoshikawa H.
      • Aber J.L.
      • Beardslee W.R.
      The effects of poverty on the mental, emotional, and behavioral health of children and youth: Implications for prevention.
      ). Their mental health issues are compounded by complex social problems that intensify their daily stress and drain emotional resources (
      • Hodgkinson S.
      • Godoy L.
      • Beers L.S.
      • Lewin A.
      Improving mental health access for low-income children and families in the primary care setting.
      ). As data from the Adverse Childhood Experiences (ACEs) study reflect, these children have often suffered multiple traumas with enduring effects (
      • Ballard E.D.
      • Van Eck K.
      • Musci R.J.
      • Hart S.R.
      • Storr C.L.
      • Breslau N.
      • Wilcox H.C.
      Latent classes of childhood trauma exposure predict the development of behavioral health outcomes in adolescence and young adulthood.
      ,
      • Bright M.A.
      • Knapp C.
      • Hinojosa M.S.
      • Alford S.
      • Bonner B.
      The comorbidity of physical, mental, and developmental conditions associated with childhood adversity: A population based study.
      ).
      The lack of access to mental health services is a complex issue rooted in child mental health provider shortages as well as the lack of specialty child mental health service sites, particularly in rural areas (
      • Behrens D.
      • Lear J.G.
      • Price O.A.
      Improving access to children's mental health care: Lessons from a study of eleven states.
      ,
      • Cummings J.R.
      • Case B.G.
      • Ji X.
      • Marcus S.C.
      Availability of youth services in US mental health treatment facilities.
      , ). The traditional structure of child treatment, which requires an intake appointment and several follow-up visits, can also impact access for working-class families (Goodman, Pugach, Skolnik, & Smith, 2013). Barriers to health care access often preclude youth from receiving preventative and early interventions, which are increasingly recognized as effective in decreasing depressive symptoms in children (Brown et al. 2018).
      Stigma impedes access and help-seeking behaviors (
      • Corrigan P.W.
      • Druss B.G.
      • Perlick D.A.
      The impact of mental illness stigma on seeking and participating in mental health care.
      ). Children and families who are labeled as “different” become marginalized from mainstream economic and social benefits of society, thereby compounding their risk for inadequate health services and poor health outcomes (
      • Stuart H.
      Reducing the stigma of mental illness.
      ). In our society, parental blame for their child's mental illness has “been a mainstay of societal and even professional attitudes” (
      • Martinez A.G.
      • Hinshaw S.P.
      Mental health stigma: Theory, developmental issues, and research priorities.
      , p 1010). Another deeply embedded attitude is that children are too young to need mental health treatment and are overmedicated by providers, a mindset that bleeds into many of the institutions that touch children's lives (
      • Corrigan P.W.
      • Druss B.G.
      • Perlick D.A.
      The impact of mental illness stigma on seeking and participating in mental health care.
      ).

      Response and Policy Options

      Federal and state agencies have put significant effort toward improving systems of mental health care for children. The Substance Abuse and Mental Health Services Administration's (SAMHSA) Children's Mental Health Initiative has funded over 300 demonstration and extension grants since 1993. These grants to states, counties, and tribal entities have realized gains in creating systems of care that are more responsive to children with serious mental health conditions and their families (US DHHS, 2016). On the state level, numerous coalitions have formed to influence policy around the availability of effective child mental health services. Notwithstanding several exceptions, the overall ratings of states on child mental health and services provided to children continue to be poor (
      Child Welfare Information Gateway
      Statistics on child and family well-being.
      ). National and state reports echo an overall lack of national progress towards improving children's mental health, and large swaths of the nation have made little advancement in access to services and improving child well-being (
      Federal Interagency Forum on Child and Family Statistics
      America's children: Key National Indicators of Well-Being, 2015.
      ,
      Mental Health America
      The state of mental health in America 2018.
      ,
      • Radley D.C.
      • McCarthy D.
      • Hayes S.L.
      ).

      Academy Position

      The Academy has long supported policies that ensure the health of the nation's children. It has been equally invested in the mental health of children and supporting initiatives to address trauma and toxic stress (
      • Cox K.S.
      • Sullivan C.G.
      • Olshansky E.
      • Czubaruk K.
      • Lacey B.
      • Scott L.
      • Van Dijk J.W.
      Critical conversation: Toxic stress in children living in poverty.
      ,
      • Gross D.
      • Beeber L.
      • DeSocio J.
      • Brennaman L.
      Toxic stress: Urgent action needed to reduce exposure to toxic stress in pregnant women and young children.
      ). Clearly, the next step is developing systems of care that improve access, reduce disparities and promote children's healthy development. This will require a shift in how mental health services interface with vulnerable children and their families. Prevention and early intervention efforts must be pursued with equal vigor and within an ecological framework that considers the impact of family, school, social ties, and community on a child's well-being.
      Considering the confluence of trauma and mental health issues, strategies to address behavioral problems must be driven by evidence, be trauma-informed, and also aim at strengthening protective factors and building resilience (
      Bolger Center for Leadership Development
      Healthy Development Summit II: Changing Frames and Expanding Partnerships to Promote Children's Mental Health and Social/Emotional Wellbeing.
      ). Concerted effort must be directed to increasing scientific and social equity by promoting prevention efforts with vulnerable youth and assuring data collection to monitor the impact (
      • Perrino T.
      • Beardslee W.
      • Bernal G.
      • Brincks A.
      • Cruden G.
      • Howe G.
      • ...
      • Brown C.H.
      Toward scientific equity for the prevention of depression and depressive symptoms in vulnerable youth.
      ). These recommendations can be accelerated by drawing upon the capacity of nurses to both design and deliver effective child mental health care.
      Specific strategies to scale up suggested approaches include the efficient use of inter-professional teams, including RN role optimization in community-based mental health intervention and Advanced Practice Registered Nurse (APRN) leadership on interprofessional teams (). Psychiatric Mental Health (PMH) APRNs are a particularly valuable asset in expanding effective pediatric primary care (
      • Delaney K.R.
      • Nagel M.A.
      • Valentine N.M.
      • Antai-Otong D.
      • Groh C.
      • Brenneman L.
      The effective use of RNs and APRNs in integrated care: Policy implications for increasing access and quality.
      ). Growing and supporting the RN school-based work force is essential, particularly promoting mental health services within school-based clinics and aligning these services with strong care coordination (
      • Bains R.M.
      • Diallo A.F.
      Mental health services in school-based health centers: Systematic review.
      ). Building trauma-informed services demands families and children experience this orientation from the first point of contact, particularly the first point of nursing contact. Services must be family driven, culturally and linguistically competent, and mirror, as much as possible, the communities being served. Finally, the extensive network of nursing communication channels should be utilized to disseminate tools that facilitate implementation of trauma informed care.

      Recommendations

      Provide the structure for mental health screening in pediatric primary care. The Center for Medicaid and Medicare Services (CMS) add depression and mental health screening to the Core Set of Children's Health Care Quality Measures for Medicaid and CHIP. Since routine screening for mental health is a standard component of a well-child visit and supported by Medicaid, train RNs to conduct this screening. Also, include screening standards as a criterion for Primary Care Medical Home (PCMH) recognition in pediatric primary care practices.
      Broaden and strengthen integrated pediatric primary care. The American Academy of Nursing (AAN) and the American Academy of Nurse Practitioners (AANP) join with the American Academy of Pediatrics (AAP) and other national organizations to assure continued support for Title 5 Maternal and Child Health Block Grant Programs along with expanding services (telehealth) and behavioral health training for all pediatric providers. Focus provider training on trauma-informed practices that address the complex associations between trauma, social displacement, and risk for mental health issues.
      Optimize the RN role in behavioral health service delivery. HRSA broaden grants for RN retraining, emphasizing RN practice in community behavioral health and integrated pediatric primary care. Include education on providing brief interventions and care coordination, especially with schools, as well as referrals to specialty services. Gather data to assess how nurse's provision of brief interventions and care coordination impacts child and family outcomes such as treatment engagement, depression, anxiety, and unnecessary Emergency Department use.
      Strengthen the role of the school-based services and the school nurse. The National Association of School Nurses receive funding for continuing studies to optimize and broaden mental health education and training within school-based clinics. Direct CMS innovation grants at school nurses and their work in designing child mental health services in partnership with key community and school stakeholders. Strengthen school nurses’ efforts in care coordination between schools, pediatric primary care and mental health providers and reimburse these services.
      Use nursing channels to disseminate tools that develop trauma-informed services. Partner with the National Child Traumatic Stress Network to build trauma informed programs by accessing nursing channels to distribute evidence-based programs among school-based health centers, Federally Qualified Health Centers, and pediatric primary care practices. The ongoing impact of dissemination efforts should be strategically assessed.
      Increase services at community agencies where families naturally interface. CMS continue funding initiatives aimed at Medicaid Re-design and broaden payment beyond primary care practices for care coordination and psychiatric consultation. To increase mental health services at point of contact in school-based clinics and community agencies, reimburse these providers for care coordination, outreach, and consultations. CMS finance pediatric care management and behavioral health integration teams, perhaps via value-based contracts, which include an upfront per member per month (PMPM) fee as well as with gain sharing dollars.
      Increase nursing presence in state policy dialogs. State action agendas must include provisions for state-wide systems to support best practices in child mental health and for building a network of child mental health community and state agencies. Monitor progress by community health assessments that include preschool children, youth, adolescent and family mental health. Nursing leaders’ presence in these policy dialogs is essential so that legislators understand the capacity of nurses to deliver mental health interventions and why APRN's leadership in the interprofessional teams will increase access to child mental health services and broaden integrated pediatric primary care.
      Combat stigma with consistent messaging in the nursing grey literature. Use the nursing voice to change the dialog around child mental health issues and the effectiveness of treatment. Each of us has a moral imperative to promote children's mental health and by extension, to respond when a child's mental health is threatened, compromised, or disabled. With a unified commitment, every setting in which children live, learn, worship, play or work becomes an opportunity for assuring their mental well-being. Nurses should organize to explain fundamental principles of mental health in terms the public can understand.

      Acknowledgments

      This policy brief represents the work of the Psychiatric Mental Health and Substance Abuse Expert Panel and Child, Adolescent & Family Expert Panel. The authors acknowledge the assistance provided by panel members, particularly Penelope R Buschman, PhD, FAAN; Linda Lewandowski, PhD, FAAN, Jianghong Liu, PhD, FAAN; Freida H. Outlaw, PhD, FAAN; Mary Lou de Leon Siantz, PhD, FAAN and Carol Dawson-Rose, PhD, FAAN and our AAN liaison, Kim Czubaruk.

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