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Delaware seeks to fill persistent shortfall in child mental health services

The state of Delaware has seen slow progress so far in its efforts to bring specialized child and adolescent psychiatric care to Sussex and Kent counties, despite a devastating string of 11 teen suicides and 116 suicide attempts in southern Delaware last year.

Many of the suicides occurred while a special task force was examining unmet child and adolescent mental health needs following the arrest and conviction of Earl B. Bradley for sexually abusing more than 100 patients in his pediatric practice, which left Kent and Sussex County mental health providers scrambling to find skilled support for the victims.

In March 2012, the task force issued a series of recommendations for expanding care in southern Delaware, including a top-priority charge to attract at least two psychiatrists trained to work with adolescents and children to establish a private practice in Sussex County.

Lt. Gov. Matt Denn discusses the challenge of recruiting new mental health professionals for public schools.

Lt. Gov. Matt Denn discusses the challenge of recruiting new mental health professionals for public schools.

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Delaware seeks to fill persistent shortfall in child mental health services

That recommendation has proved difficult to fulfill, according to state officials.

“I think they are a significant way down the road to getting one, which would be 50 percent of the target, but it’s been a significant challenge,” said Lt. Governor Matt Denn. “As far back as anyone can remember, there’s been a shortage in Sussex County primarily but also in parts of Kent County.”

While that chronic shortage is most pronounced in southern Delaware, there is limited access to child and adolescent mental health care throughout the state, says Susan A. Cycyk, director of the Delaware Children’s Department’s Division of Prevention and Behavioral Health Services (DPBHS). The majority of psychiatric providers that work with children ages 2 to 22 are concentrated in the Wilmington area.

A Reflection of a National Problem

Delaware’s shortage of child and adolescent mental health professionals reflects a national trend.

Across the country, millions of children suffer from anxiety, depression, ADHD, autism spectrum disorders, and other mental health-related issues, according to a 2013 report from the Centers for Disease Control and Prevention (CDC). However, just a fraction of the 15 million children with diagnosable psychiatric disorders receive specialized mental health care, say behavioral health experts.

Following a 1999 finding by the U.S. Surgeon General’s office that only 21 percent of mentally ill children received mental health services, national efforts to recruit new doctors increased. However, the problem persists, says Chris Thomas, director of Child Psychiatry Residency Training at the University of Texas, Galveston, who has studied the shortage of child psychiatry specialists for more than a decade.

Thomas cites “modest gains” in recent years but says that at the present recruitment rate, “we are actually going to end up falling further behind.”

The trend is part of a general shortage of mental health providers, including psychologists, social workers, counselors, and therapists, Thomas said. The problem is amplified in rural and low-income areas, since the majority of child and adolescent mental health providers reside and work in affluent urban centers, he said.

That national shortage has made recruitment in Delaware difficult, despite efforts by the Department of Health and Social Services (DHSS) to attract practitioners by increasing reimbursement rates for local hospitals and community health organizations hiring child and adolescent psychiatrists and extending medical school loan payment assistance if practitioners are willing to work in Sussex County.

Developing an Emotional Support Network for Children

Delaware seeks to fill persistent shortfall in child mental health services
Estimates of U.S. children with mental disorders
(source: USDHSS & CDC)

In the face of recruitment challenges, the state has started to look further up the chain of care to address children’s emotional problems before the need progresses to acute psychiatric care.

“What we are trying to do is to have more and more of the services provided at the front lines at a lesser level of intensity either by a family practitioner, by a practitioner in the schools, or by other people, who can consult as needed with a child psychiatrist or child psychologist,” Denn said.

This month, Delaware’s congressional delegation announced that the state will receive $1 million in federal funding to encourage parental and family involvement in their children’s mental health care.

This latest funding will complement a series of initiatives and funding streams coming together this year throughout the state that aim to train members of the community to support children’s emotional health and to expand the network of care for children in need.

“It all starts with prevention,” said Cycyk.

“That’s why we really want to provide good after-school and summer activities that are safe. Whether [these activities] are academic, cultural, sports-based, nature-based, or faith-based, the adults working with these kids need to be trained in recognizing mental health needs and know how to connect families with treatment systems.” Cycyk said.

The recently passed fiscal year 2014 state budget allocates $2.2 million to the DPBHS to help expand and improve after-school and summer programs. This month, the agency will disperse an initial $200,000 of that funding in mini-grants and will issue a request for proposals from after-school programs later in August for funding during the school year, Cycyk said.

Cycyk hopes that increasing kids’ opportunities to spend time in healthy environments will not only will help keep them healthy but also will expand the safety net of caring adults able to recognize the warning signs of emotional troubles. With that aim, the DPBHS will require that all grant recipients complete violence and suicide prevention training.

Equipping the School System

Delaware seeks to fill persistent shortfall in child mental health services
AACAP child psychology workforce maps by state (external link)

“If you catch these kinds of problems as soon as you can, you can work on the issues within the child’s environment and try to get the best treatment as quickly as possible,” Cycyk said.

That’s the theory behind Governor Jack Markell’s latest initiative to place 30 behavioral health consultants in the state’s middle schools, at least one consultant in every district. In June, the legislature approved $3.3 million for the new positions.

“The medical professionals tell us that with a lot of kids that have depression-type problems in high school, you first begin seeing some warning signs of that in middle school,” Denn said.

While one-third of Delaware elementary schools have mental health counselors connected to early intervention programs, and nearly all of the state’s high schools have wellness centers with mental health professionals, only three middle schools have any staff members trained specifically in addressing students’ emotional needs, Denn said.

These new behavioral health consultants will be available to students on a walk-in basis, provide training for teachers and staff, and offer counseling sessions with families, Cycyk said.

The DPBHS will be responsible for contracting the behavioral health consultants. However, Cycyk does not expect recruitment to be easy. She anticipates that placements might not be finalized until well into the upcoming school year.

While Cycyk and Denn both are optimistic that these efforts will help improve the overall mental health of children in the state, they know that no amount of prevention and early intervention can eliminate the need for specialized care.

Fostering Pediatrician and Psychiatrist Collaboration

The 2012 task force’s examination of existing child mental health services in southern Delaware found that children in Sussex and Kent counties had to wait up to eight weeks to see a psychiatrist.

An investigation by the Centers for Disease Control (CDC) into the series of adolescent suicides in southern Delaware revealed that several of the troubled teens and young adults had previously sought counseling and had to wait several weeks for services.

Pediatricians and family practitioners are often left to fill the gap; however, they are not specifically trained in psychiatric medicine, says Dr. Mark S. Borer, a Dover-based child and adolescent psychiatrist who serves as the Delaware delegate to the American Academy of Child and Adolescent Psychiatry.

“Lots of times primary care physicians (PCPs) are uncomfortable prescribing because they don’t know the meds or the side effects they should be looking out for,” Borer said.

In an effort to support these primary care physicians, Borer has developed a collaborative program that enables PCPs to consult with licensed psychiatrists about specific patients.

Borer’s program provides peer-reviewed forms that can be exchanged between primary care doctors and psychiatrists. Patients and family members can also provide detailed background information.

Cycyk expects that the state will address reimbursement for PCP-psychiatrist consultation during the upcoming rewrite of the Delaware Medicaid code pertaining to children.

“If we can help the child get help at the pediatrician right where they are, they might not have to be referred to a psychiatrist,” Cycyk said.

For those that do need the expertise of a psychiatrist, the DPBHS is also looking at telepsychiatry as a means of bringing care closer to home. Telepsychiatry allows a patient to meet with a psychiatrist in another town, county, or even state through a secure videoconferencing system.

Borer says telepsychiatry has potential, though with limitations at present, such as the ability to observe subtle medication side effects, such as tremors, on a video screen.

“Whenever possible, you want to use your more local professionals… they know the Delaware area, the other doctors, and the schools,” Borer said. “You don’t want to use [telemedicine] as your main access to care, but it can be very useful to intervene when we are really scared for a kid.”