October 27, 2007

1. AAP Section on Residents Annual Advocacy Campaign:Pediatric Mental Health October 27, 2007

2. Overview • Demographic of pediatric mental health • AAP Stance on Mental Health • Barriers to Mental Health • Residents as Advocates • Forums for Advocacy • Patient Advocacy • Community Advocacy • State Legislative Advocacy • Federal Legislative Advocacy

3. Pediatric Mental Health • Mental health is an integral part of a child’s overall health & wellbeing. • More than 1 out of 10 children (0-17 years old) suffer from a mental health disorder. • Less than 20% of those with mental health disorders receive treatment.

4. Pediatric Mental Health • “The prevalence of mental disorders among children is predicted to rise in the next 15 years by 50%, becoming a major cause of morbidity, mortality and disability.”(Surgeon General’s Conference on Children’s Mental Health, 2000) • Suicide is already: 4th leading cause of death between ages 10-14 yo 3rd leading cause of death between ages 15-24 yo

5. Pediatric Mental Health • Most common pediatric mental health disorders include: • Anxiety disorders (most common) • Mood disorders • Attention Deficit Hyperactivity Disorders • Autism Spectrum Disorders • Conduct Disorders • Eating Disorders • Substance abuse

6. Pediatric Mental Health • Undiagnosed, untreated, or under-treated pediatric mental illnesses have been linked with: • School failure • Suicide • Substance abuse • Violence • Homelessness • Incarceration

7. AAP Stance on Mental Health • The AAP has a long standing interest in mental health access for youth. • The AAP developed a consensus statement in 2000 entitled “Insurance Coverage of Mental Health & Substance Abuse Services for Children & Adolescents.” • The AAP was joined by other groups including the American Academy of Child & Adolescent Psychiatry, American Psychological Association, & the American Psychiatry Association.

8. AAP Stance on Mental Health • The AAP consensus statement addresses 3 issues: access, coordination, & monitoring. • It states that "these issues should be considered from the standpoint of needs for preventative interventions, direct mental health and substance abuse services, and coordinated multi-service care." (Pediatrics 2000; 106; 860-862)

9. AAP Stance on Mental Health • Recognizing the need for increased mental health care in the context of primary care, the AAP chartered the Task Force on Mental Health at the end of 2004. • The Mental Health Chapter Action Kit was developed through this task force & is available at: http://www.aap.org/mentalhealth/mh2ch.htmlWithin it, you can find valuable resources such as “the clinician feedback form” & “how to develop a community resource guide.”

10. Barriers to Mental Health Services • Stigma among families to bring up mental health concerns with doctors. • Inadequate identification of youth with mental health issues. • Mental health provider shortages. • Inadequate coverage of mental health services by both public & private health insurance programs. • Complex & fragmented service delivery systems.

11. Barriers for Pediatricians • Lack of time during an appointment to address mental health. • Lack of training, expertise, & comfort with mental health identification or treatment. • Lack of payment or compensation for providing mental health services. • Lack of knowledge regarding community mental health referral services. • Lack of mental health referral services in the community.

12. Advocacy Among Pediatric Residents • Can advocate for our patients on many different levels. • Can personally choose the level we feel most comfortable & effective at. • Can advocate for our patients within our time limitations. • Can help create the changes we believe are needed in the field of pediatrics. • If we do not advocate for our patients, who will?

13. Advocacy at the Individual Patient Level • # 1 barrier to pediatric mental health is lack of diagnosis or identification. • Work on understanding signs of mental disorders. • Screen patients within your own continuity clinics. • Talk about mental health concerns or questions with the family as part of your well child visit.

14. Advocacy at the Individual Patient Level • Increase awareness at your clinics regarding suicide prevention & crisis hotlines. • Find out the numbers of your community’s help lines. • Create posters & wallet sized cards with these or local numbers: • 1-800-SUICIDE (suicide prevention/crisis) • 1-800-273-TALK (counseling, suicide prevention, mental health referrals)

15. Advocacy at the Community Level • Although we may not have the time to extensively treat a mental health disorder, we can make effective community referrals. • Learn about the resources available in your community. • Spread the word about what is available to your fellow residents. • Contact the community resources to build a better relationship with your clinic. • Find out which community resource is the most comprehensive & effective by speaking with other community members & psychiatrists.

16. Advocacy at the Community Level • If there are few community resources available, take action. • Write op-ed pieces to your city/town newspapers about the need for more resources. • Contact your mayor, city council, or school board about the need for more mental health resources from your stance as a pediatrician.

17. Advocacy at the State Level • 33 states currently mandate that certain insurers provide varying levels of “parity” or equality in coverage between mental health benefits and medical benefits. • 16 states mandate that certain insurers provide specific mental health coverage. • Only Wyoming currently has no mental health insurance mandates.

18. Advocacy at the State Level • In 2007, 10 states introduced legislation targeted at expanding mental health coverage. • 4 states (Colorado, New Mexico, Washington, West Virginia) passed legislation strengthening existing mental health parity laws. • No state has enacted legislation targeting increasing access to mental health for children & adolescents.

19. Advocacy at the State Level • Contact your local AAP chapter to find out about mental health legislation that is being discussed within your state. • Find your AAP chapter legislative contacts by going to: http://www.aap.org/member/chapters/chapters.htm • Find out how you can become more involved with your AAP chapter’s legislative efforts.

20. Advocacy at the State Level • Be a leader for pediatric mental health in your state! • Find out who are your state representatives by going to www.congress.org • Learn more about pediatric mental health at the state level by reading the AAP Child & Mental Health Issue Brief. • The AAP Division of State Government Affairs is available to act as a resource to you as you work with your chapters on state advocacy issues.

21. Advocacy at the Federal Level • There are currently 2 bills at the federal level that would increase insurance coverage for pediatric mental health: • SCHIP: Children’s Mental Health Parity Act • Mental Health Parity Act of 2007

22. The SCHIP Children’s Mental Health Parity Act • S. 1337 is a bill to ensure the parity of mental & medical care in programs operated under the State Children's Health Insurance Program (SCHIP). • The bill would require that states offering both medical & mental health coverage to children offer mental health coverage that is not more restrictive than medical coverage in terms of "financial requirements and treatment limitations."

23. Mental Health Parity Act of 2007 • S. 558/H.R. 1424 will improve the mental health of all Americans, especially children & adolescents. • Would require businesses that offer mental health insurance to provide equal coverage for both physical & mental health services. • Would require parity in co-payments, deductibles, out-of-pocket expenses, covered hospital days, outpatient visits, and substance abuse treatments.

24. Mental Health Parity Act of 2007 • Businesses with less than 50 employees would be exempt from the requirement. • Employers can opt-out if the requirement would increase their health care costs by over 2% the first year or over 1% for subsequent years.

25. Advocacy at the Federal Level • Find out who your Senators & House representatives are by going to: http://aap.grassroots.com/electedofficials/ • Sign & send copies of the AAP Mental Health Parity letter of support found at: http://aap.grassroots.com/mentalhealthparity/ • Start a letter writing campaign within your residency program.

26. Advocacy at the Federal Level: Be a Key Contact • Key Contacts are AAP members who have agreed to take their advocacy to the next level by developing an ongoing relationship with their respective federal legislators. • The Key Contacts program serves as a critical supplement to the work accomplished by the Federal Advocacy Action Network (FAAN) and the AAP Department of Federal Affairs.

27. Advocacy at the Federal Level: Be a Key Contact • Key Contacts will receive more sophisticated assignments from the AAP Department of Federal Affairs than FAANs and are expected to report back their results. • Contacts should be ready to respond to requests for action and become a resource for their federal legislators at critical decision points. • Being a Key Contact requires a very small time commitment but can yield big results.

28. Advocacy at the Federal Level: Be a Key Contact • Receive all the benefits of the FAAN program and more, including: * Free resources and tools to expand advocacy skills. * Techniques for relationship-building with your members of Congress. * Latest up-to-date information on legislation affecting pediatricians. * More sophisticated assignments for the advanced advocate. • To sign up go to: http://aap.grassroots.com/keycontact/

29. AAP Annual Legislative Conference • Yearly conference in Washington D.C. • Sponsored by the Committee on Federal Government Affairs (COFGA) & the Committee on State Government Affairs (COSGA). • Designed to bring pediatricians first-hand legislative advocacy experience. • Two days of interactive workshops and stimulating speakers.

30. AAP Annual Legislative Conference • At the conclusion, attendees meet and lobby members of congress (or their aides) to support an AAP endorsed bill (this year the focus was on SCHIP). • Provides an excellent introduction to the world of legislative advocacy for beginners as well continued experience for seasoned advocates. • A wonderful event for networking.

31. Conclusion • Pediatric mental health is an issues that is often overlooked as part of the general health of children. • Pediatric residents can play key roles as advocates on many different levels. • We can decide for ourselves what level we feel most comfortable & effective at. • We can then strive for the changes we hope to see for the lives of our patients from the standpoint of a pediatrician & an AAP member.

32. Key Internet Resources • http://www.aap.org/mentalhealth/ • http://www.aap.org/member/chapters/chapters.htm • http://www.aap.org/securemoc/statelegislation/mh_issuebrief.pdf • http://www.aap.org/moc/statelegislation/ • http://aap.grassroots.com/electedofficials/ • http://aap.grassroots.com/mentalhealthparity/ • http://aap.grassroots.com/keycontact/ • http://www.congress.org/congressorg/home/

33. References • Surgeon General’s Conference on Children’s Mental Health, 2000. • AAP Consensus Statement on Pediatric Mental Health. Pediatrics 2000; 106:860-862. • AAP Committee of Pediatric Emergency Medicine. Pediatric Mental Health Emergencies in the Emergency Medical Services System. Pediatrics 2006; 118:1764-1767. • AAP Mental Health Chapter Action Toolkit, 2007. • AAP Policy Statement. Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental Surveillance and Screening. Pediatrics 2006; 118:405-420. • AAP Policy Statement. The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care. Pediatrics 2001; 108;1227-1230. • State Laws Mandating or Regulating Mental Health Benefits. Washington, DC: National Conference of State Legislatures. January 2007.

34. References • Foy EF, Earls MF, and Horowitz DA. Working to improve mental health services: the North Carolina advocacy effort. Pediatrics 2002; 110:1232-1237. • Koyanagi C, Boudreaux R, and Lind E. Mix and Match: Using Federal Programs to Support Interagency Systems of Care for Children with Mental Health Needs. Washington, DC: Bazelon Center for Mental Health Law. 2003. • Seltzer T. Teaming Up: Using the IDEA and Medicaid to Secure Comprehensive Mental Health Services for Children and Youth. Washington, DC: Bazelon Center for Mental Health Law. August 2003. • Williams J, Shore SE, and Foy JM. Co-location of mental health professionals in primary care settings: three North Carolina models. Clinical Pediatrics 2006; 45:537-543. • Wishmann A, Kates D, and Kaufmann R. Funding Early Childhood Mental Health Services and Supports. Washington, DC: Georgetown University Child Development Center. March 2001. • Wood EP. Children and Mental Health Parity. Washington, DC: National Conference of State Legislatures. May 2005.

35. Presentation created by the AAP Section on Residents Leadership/Advocacy Committee Committee Chair: Mana Golzari, MD