Taming the Crisis in Child Psychiatric Care

By Joseph Gold, M.D. and
Bruce M. Cohen, M.D., Ph.D

Belmont, Massachusetts
June 15, 2000

There is a baby boom underway in Massachusetts. The bright side is young faces and young dreams. The sad side is an increase in the number of children with psychiatric disorders and children who suffer the effects of abuse.

Most citizens are aware of the increasing pressures on school systems to provide services to our growing population of children. They may not be aware of a similar crisis in mental health services. They may, also, not be aware that with growing need there has been no growing support. In fact, while spending on education nationally has increased in the last decade, spending on medical care, adjusted for inflation, has declined a few percent, and spending on psychiatric care has been cut more than one third. Moreover, lack of readily accessible community-based and hospital care leaves children and families without the help they urgently need.

The recent articles on psychiatric care for children are laudable and appreciated. They confirm what clinicians and emergency rooms know: The sheer number of children in psychiatric crisis has increased dramatically. State agencies and health care systems have been able to respond only partially to date.

This is not a debate over whether these children need help. They have serious and well-documented illnesses that are known to improve with treatment. No less than diabetes or meningitis, these illnesses have proven biological and environmental risk factors. We can take pride that much of our newest knowledge of the nature, genetics and treatment of childhood psychiatric disorders and child abuse comes from work by local researchers and clinicians. They, and others nationwide, have developed new preventive and treatment approaches.

We can also take pride in new initiatives and new coordination among state agencies to turn our growing knowledge about how to help children into an effective system of care. The Department of Mental Health (DMH) has successfully stressed family-driven decision making, increased the diversity and cultural competency of its staff, and supported programs that treat children in settings as close to normal life as possible. The Department of Social Service (DSS) has designed CommonWorks, a case management system that decreases the disruption of care to children in their custody. Inter-agency agreements to help children are now routine, and blended funding streams to maximize the impact of monies spent are being implemented. In a notable example, the DSS, the Division of Medical Assistance (DMA) and the Massachusetts Behavioral Health Partnership (MBHP) have jointly created transitional care units at the Franciscan and McLean hospitals. These are supervised residences for children and adolescents who would otherwise have prolonged inpatient stays.

Unfortunately, these novel, more humane and more effective approaches are limited, mostly due to limited funding. Adequate funding would permit multi-tiered, outpatient and community-based services that not only could prevent unnecessary and expensive hospital stays, but could also address root causes that lead to a deterioration in health in the first place. Adequate funding of inpatient services and residences, when needed, and outpatient and home care, whenever possible, would bring expert help to children and families when they are most vulnerable. Failure to provide proper financial support for each level of care will lead to more children "stuck" in hospitals, and lack of access to care will worsen the eventual outcome for a generation of our citizens.

The Legislature’s recent passage of the mental health parity bill was a notable advance, bringing public policy in line with the knowledge that psychiatric disorders are medical illnesses that demand treatment. Similarly, the Legislature’s approval of an additional $10 million for children’s mental health services represents a major step toward solving existing problems. Collectively, we have the scientific and programmatic expertise and a new spirit of cooperation among public agencies needed to address the crisis in child psychiatric care. The remaining question is will we support our legislators and public officials in advancing programs to help our children? Do we have the resolve and decency as a society to commit more resources for the growing number of Massachusetts children who need our help?

Joseph Gold, M.D., is clinical director of the McLean Hospital Child and Adolescent Treatment Program and Director of Community Services to Children for Partners Psychiatry and Mental Health. Bruce M. Cohen, M.D., Ph.D., is president and psychiatrist in chief of McLean Hospital.