Got Barriers? Improving Access to Mental Health Care for Children and Adolescents

Guest author: Melanie Washington, MSW, MPH, PhD

If it were not for social work interventions I had as a child, my life trajectory may have been completely different.  I am eternally grateful for those individuals who, with moderate intervention, helped to shape the individual that I am today and be a part of what facilitated the passion that I have for mental health care for children and adolescents.  With my life experiences, both personally and professionally, I fervently believe that every child deserves the opportunity to have mental health treatment, therefore it is my hope through my future work we will be able to figure out solutions to help increase access to mental health care for all children.

I had my first interaction with a social worker in second grade.  I was fortunate to have parents who recognized the struggle that I was having and were unconcerned about the stigma of seeking mental health treatment.  In general, I was an irritable, angry, and strong willed child, with a low sense of self-worth (it wasn’t until I was an adult that I was diagnosed with depression and learned that this is often how depression presents in young children).  However, at school, I was shy and quiet, allowing myself to be walked on by my peers and then I would come home and take it out on my family, verbally and physically.  It was through family and individual work that I was able to start making improvements and gaining more confidence in myself.

Then in sixth grade, I became well acquainted with the school social worker who assisted me in dealing with tremendous challenges and stress at home (although this time I was not the cause of it).  Her assistance and support shaped not only my personal trajectory, but also my career.

After obtaining my bachelors in social work, I worked as an intake coordinator in an outpatient mental health clinic for children and adolescents; I saw the heartache and immense challenges caregiver’s face in attempting to access treatment for their children.  Therefore, I made the decision to go back to school to become a researcher to find solutions to this issue.  I have also begun working on an exciting new grant funding a white paper exploring the issues of access to child and adolescent mental health care in Western New York.

• Children globally (1 out of 4) have at least one diagnosable mental health disorder.
• There are not enough child mental health providers to meet the current needs within the population.
• The World Health Organization has estimated a 50% increase in childhood mental health needs by 2020.

Potential (and too often) Real Barriers:

• Financial barriers:
  • Insurance coverage- plan may not include mental health services, minimal number of visits allowed, therapists may not be “in network”, may have high deductible plan
  • No insurance
  • Co-pays and families without money to pay the co-pay
  • Sliding fee scales- if they are offered, still may not be low enough for families to afford the payment
• Geographic barriers: There may not be any clinics in the communities in which individuals live. If a child is below the age of 5, the family may have to travel further distances to find a therapist willing to see children under this age
• Transportation barriers: Does the family own a car? Can they afford gas? If not, do they have access to Medicaid funded transportation or have money to take the bus? Is your clinic on a bus line? How many bus transfers would might families have to take to get to the office? Is there enough time for the family to take the bus to the appointment after they get out of work? Is the family ashamed or embarrassed to tell you that they don’t have the adequate transportation to access services?
• Organizational barriers:
  • Hours of operation: Do the clinic hours of operation provide enough flexibility for days, evenings and weekend appointments or does the schedule of therapy create a barrier to access?
  • Does the clinic engage in practices of double booking that can cause people to wait past their appointment time when both appointments show up as scheduled and someone has to wait? These delays may not be tolerable for the children and adolescent or their family due to behavioral and schedule needs (such as the last bus leaves before their appointment ends).
  • Is there enough diversity in the sex and race/ethnicity of therapists so that families have a choice of someone they feel comfortable with?
  • Are there therapists who have appropriate specializations to work with diverse clientele in a clinic as well as evidence-based treatment skills to provide effective treatment?
  • Is the organization trauma-informed and trauma-sensitive so that people seen feel safe and welcome, and are not re-traumatized through service provision?
• Availability of services:
  • Is a family able to easily obtain an appointment when they first call? If not, what does the process entail for a family to get one? How long do they have to wait for the first appointment? How are they treated by the person who handles the initial contact with the agency? Does the family feel cared for, engaged and that their social or cultural differences will be recognized and understood?
  • If an appointment is given, is it within a reasonable period of time?
  • Are there therapists available to take on new clients?
  • Are there delays or interruption in service being provided- for example if an agency has a high turnover rate, how long to families have to wait to see a new therapist when their current one leaves, and what impact might that disruption in services have on the child?
• Lack of awareness and willingness to access care:
  • Caregivers may not recognize the signs that a child or adolescent needs mental health treatment. Or they feel there is a stigma related to this. How to we help educate them?
  • Caregiver may be unsure about how to access care, who to ask, and how to navigate the mental health system. Their primary physician also may not be knowledgeable about how to assist them. How do we help them find access to care?
  • Fear: Caregivers may be fearful that if their child does need mental health care that they will be blamed for their child’s behavior or that their child will be taken away from them. Social workers are often equated with Child Protection Services and the myth that CPS only takes away children from families. How do we educate families that therapists can help?

There are many barriers faced by families as they attempt to obtain mental health services for their children.  Yet I passionately believe we also have also have the ability to create some solutions for children and adolescents, their families, mental health care organizations, and the research and policy community.

• Take action! If you are concerned about your child, talk to their primary care doctor or school social workers.
• Keep a positive attitude: Help is available and the sooner mental health issues receive effective interventions, the healthier the outcome will be for the child and family.
• Don’t worry: Getting mental health help for your child does not mean you are a bad parent!
• Communicate (there is a questions at the end of this post to ask of different providers) with your child’s providers and advocate for them if you do not like the way services are provided. (There is a link at the end of this post on the family resource page with 25 ways to advocate for your child.)

 Possible Solutions for Organizations:

• Improve engagement and retention of clients by following Trauma-informed Care (TIC) principles and educate all staff at the clinic, from the receptionist to the director on TIC. (Refer to the resource section at the end of this post.)
• Review and adjust, if needed, clinic hours of operation to ensure they meet the needs of family schedules.
• Attempt to hire a diverse group of individuals and provide training in cultural competency.
• Advance the education of your workforce to enhance their skills in treatment provision including evidence-based treatments
• Include access to services in agency strategic planning.
• Review and adjust, if needed, your intake process. For example: is there a way to streamline it and make it more family friendly, decrease the waiting times for services, etc.?
• Review and adjust, if needed, scheduling so that clinicians can see their clients at the time that their appointments are scheduled.
• Pursue grants or a charitable fund to assist families who are unable to cover the cost of services, bus passes to get to the clinic, and other needs that create barriers to access.
• Consider, if possible, performing home or school visits for families who have transportation issues.

Possible Large System Solutions:

• Enhanced integration of physical and mental healthcare
  • Mental health screenings in pediatric clinics, starting from birth
  • Having mental health professionals on staff so that a child or adolescent screens positive they are able to see someone immediately, in addition to providing regular treatment
• Enhanced integration of mental health clinics into schools or increase of therapists within schools who are able to provide regular psychotherapy, as opposed to crisis management
• Evaluate tele-mental health: To assist with families to who have transportation issues or may not have easy geographic access to a mental health clinic. Yes, billable regulations need to be investigated and policy advocacy may be part of this with funding bodies.

New York Child and Adolescent Psychiatry for Primary Care

SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach

US Dept. of Health & Human Services. Access to Adolescent Health. Access to Mental Health Care

American Psychological Association. Strengthening the Child and Adolescent Mental Health Workforce

American Psychological Association. Increasing Access and Coordination of Quality Mental Health Services for Children and Adolescents