1. Nelson, Roxanne BSN


Integrating mental health consultants and providers into schools and primary care could help.


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Last year, a teenage boy walked into Marjory Stoneman Douglas High School in Parkland, Florida, activated a fire alarm, and opened fire with a semiautomatic assault rifle. By the time the shooting was over, 17 people were dead, and many were severely wounded.

Figure. High school ... - Click to enlarge in new window High school students at Westerville North High School in Westerville, Ohio, sign their names on a "Say Something" banner, part of the district's effort to encourage a culture of looking out for one another and noticing signs in students' behavior that could lead to students hurting themselves or others. Photo courtesy of Theresa Black.

As with prior incidents, this shooting was followed by discussions in the media about gun control and mental health care-and the need for improvements in both areas. The 19-year-old Parkland shooter had a long history of disturbing behavior. In the 10 years before the shooting, local law enforcement agencies received at least 45 calls about him or his brother related to erratic behavior, domestic violence, and child or elder abuse. The shooter was never taken into custody or referred for mental health counseling. Although an extreme example, the Parkland shooting illustrates how childhood mental health issues still aren't receiving sufficient attention.



Recent studies support the need for more mental health services for our youth. In a study by Whitney and Peterson published online February 11 in JAMA Pediatrics, the researchers found that about half of U.S. children who had a treatable mental health disorder didn't receive treatment from a mental health professional. They used data from the 2016 National Survey of Children's Health to ascertain recent national- and state-level estimates of the prevalence of mental health care and treatable mental health disorders in children younger than 18, excluding children without health insurance and those younger than six. Of the estimated 46.6 million children included for analysis, about 7.7 million, or 16.5%, had at least one mental health disorder. Prevalence varied considerably by state, ranging from 7.6% in Hawaii to 27.2% in Maine. There was also a wide range among states when it came to children not receiving treatment for a mental health disorder, from 29.5% in Washington, DC, to 72.2% in North Carolina.


According to America's Health Rankings Annual Report 2018 from the nonprofit United Health Foundation, the southeastern states have some of the lowest health rankings, based on 35 measures including behaviors, community and environment, policy, clinical care, and outcomes data. Alabama, for example, was found to have the lowest concentration of mental health providers (85 for every 100,000 people).


In a study published in the American Journal of Preventive Medicine in March, Fontanella and colleagues compared suicide rates among 10-to-18-year-olds enrolled in Medicaid with those of youths not enrolled in the program. The study sample comprised all youths who died by suicide between 2009 and 2013 in 16 states. (These states accounted for 65% of the total number of U.S. children on Medicaid and included the 10 states with the largest populations.) The researchers concluded that approximately 39% of total suicide deaths in youths in these 16 states occurred among Medicaid recipients (1,563 versus 2,482 deaths among youths not in the program).


The overall suicide rate did not differ significantly between the two groups studied, and in both groups the highest rates of suicide were found among older teens and males. However, there were notable differences between the two groups according to age and sex. In the Medicaid group, the risk of suicide was 28% greater among children 10 to 14 years old and 14% greater among females of any age. Moreover, the method of suicide differed between the two groups: most suicides in the Medicaid group occurred by hanging or suffocation (54.6% of male suicides and 72.3% of female suicides). The risk of suicide by hanging, according to the researchers, was 26% greater among youth enrolled in Medicaid.


The authors note that these findings, along with previous research, indicate "Medicaid subgroups experience more child maltreatment and poverty-related adversity than non-Medicaid youth [and] suggest a need to develop the capacity of healthcare delivery systems to implement trauma-informed approaches across the continuum of care."



There are barriers to mental health care, says Deborah Gross, DNSc, RN, FAAN, Leonard and Helen Stulman Endowed Professor in Psychiatric and Mental Health Nursing at the Johns Hopkins School of Nursing in Baltimore, Maryland. "The way the system is set up does not facilitate the kind of early and nonstigmatizing intervention that children and families need." Gross explains that only providers in mental health clinics are reimbursed. "But the best way to provide early intervention to children is not in a mental health clinic but to embed the provider into primary care or in the schools."


She emphasizes that there is still a lot of stigma associated with going to a mental health clinic and therefore many reasons why people don't want a record of their mental health care. "This is especially true for those living in poverty," Gross says, "and the only way to get Medicaid reimbursement is to get a psychiatric diagnosis. And that's a big barrier, because parents don't want their children to have a psychiatric diagnosis." Yet schools increasingly have to deal with mental health issues, she added. "The teachers cannot teach, because there's so much trauma and behavioral health problems in the children. We need to do much more to integrate mental health consultants and providers into schools, because that's where the children are."


Factors driving the situation with mental health largely echo health care overall, notes Daniel G. Whitney, PhD, an associate professor in the Department of Physical Medicine and Rehabilitation at the University of Michigan, Ann Arbor, and lead author of the JAMA Pediatrics study. "In addition, access, affordability, and open communication about mental health disorders and seeking treatment for these conditions can also be salient factors." He explains that nurses could play a potential role by integrating mental health screening into routine clinical care and checkups for children. "Talking with parents about mental health for their children, such as being aware of signs and symptoms, [and providing] resources to contact if they suspect their child has a mental health disorder would be very beneficial," says Whitney.


According to Gross, psychiatric nurses could help expand the mental health workforce. "Unlike psychiatrists, who are trained to treat either adults or children, psychiatric NPs are trained in life span," she says. "And they are far more willing, able, and interested in working with families in poverty." But at the state level, there are still barriers to practice for NPs. "These barriers impact the ability to function, and reimbursement for nurses is low," Gross explains. "There's not a lot of incentive to go into mental health, and that's true for psychiatrists as well as nurses."


Efforts are underway to improve reimbursement rates, incorporate family-focused interventions, and implement mental health programs in primary care settings. But thus far, reimbursement continues to be a problem, Gross says. "Pediatricians have about 10 minutes with a patient the way the current system is set up. The Affordable Care Act was designed to expand prevention, but I'm not sure that's being continued, and there's been increasing limitations placed on Medicaid." On the system level, she adds, nurses can play an important role in changing policy, removing barriers to practice, and bringing together more collaboration in mental health care.-Roxanne Nelson, BSN