Thursday, May 8, 2008

"Our kids aren 't broken. The system is broken."

As regular readers (and to my eternal surprise, there ARE regular readers) of this blog know,  S.B 2518 is getting closer to reality.  As with all things legislative, it is not always clear how this bill will help the families with whom we work.  I thought it might be useful to look at a specific family with whom I have been working over the year, and think about how SB 2518 might have eased the pain of their struggle over the course of the last year.
The quote in the title came from the recent forum on Children's Mental Health, held in Worcester last week (when I began my sojourn into the Hawaiian rain forest), and seemed appropriate to describe Kenny B., a ten year old boy who came into to see me with his father last fall.  Ken had been diagnosed with ADHD several years ago, using the AAP protocols, and had actually done pretty well with treatment based on some classroom modifications (a 504 plan) and a low dose of stimulent medication.  Last spring, however, he started having angry outbursts at school that were very different from the sorts of behaviors he had had earlier in his life- something seemed different.  We referred his family to a behavioral therapist and a child psychiatrist, and sort of lost tract of them after that (confidentiality within the mental health community is a habit- collaborative care of families is difficult).  When I "remet" Kenny last fall, he was on a combination of five psychotropic medications, he had been suspended from school weekly since school began, he had been to Emergency Mental Health weekly since school began, and he had managed a 7 day inpatient stay, with little change in his therapy and NO discussion between the inpatient psychiatrists and any of his outpatient doctors.  On discharge, the family had been told to contact his psychiatrist, who was on vacation for 2 weeks.  So, not knowing what else to do, they came back to us, without answers, many questions, 5 drugs and all.  All of this, you can imagine, was playing havoc with his family.  Both parents worked, in daytime jobs that were located in the direction opposite of his school, therapist and pschiatrist (and this was before the gas prices had skyrocketed). 
I was suitably troubled by the situation, but realize that, in order to treat this child with serious emotional disturbance, I needed more information and help.  I sought out a Family Stabilization Team, but was told that his private insurance would not cover that service.  Weekly therapy, psychiatrists, hospitalizations and EMH were fine- just not intensive services designed to help manage children in the milieu in which they are most comfortable.  So I got releases of information to talk to everyone, and spend a fair bit of time talking to his school (very helpful), therapist (very helpful), psychiatrist (on vacation) and place of hospitalization, who send me a discharge summary with no clear diagnostic formulation and the words "r/o Asperger's" on it.  We spoke with DSS about voluntary services (none available at this time), DMH about case management (don't do Asperger's, even though I said it wasn't Asperger's) and the insurance company (that's all we can do, thank you).

About that time, he ended up in EMH again, although this time the family contacted me, and I was able to provide the admitting hospital with a more complete picture of what was going on.  
At the second hospitalization, the psychiatrist and psychologist finally figured out what had changed last spring- he has developed auditory and visual hallucinations, and his dissociation was at the root of much of his dysfunction.  He is now diagnosed into a DMH approved category, treated with more appropriate medications and the various components of his treatment team are speaking to each other.  The family knows that this is going to be a long and difficult road, but at least now they are on road, instead of careening from side to side.

How would SB 2518 have helped this family?  I looked at the 5 main points that this legislation currently addresses:
• Creates a system so that school personnel will be able to receive mental health consultation and guidance. In this case, Kenny's problems presented in school, yet school and psychiatrist never talked.  Might have helped speed things along.
• Requires insurance companies to pay mental health professionals for the time they spend on “collateral services,” or coordination of care with other important adults in a child’s life. I am currently on the Physician Advocacy Fellowship, that paid for me to explore this child's life in much more detail than I would usually have been able to.   This stuff takes time, and professional time needs compensation or it stops happening.  
• Promotes behavioral health screening for children during visits to their doctors. We had already done that-  not much impact on this case.
Creates processes to move children with mental health needs to a community based or residential program. This part of the bill would have helped in our efforts to get this child into the complex web of systems managed by DSS, DYS, DTA, DMH and DMH-  to get past the silos and into some real care.

What is missing?  I still couldn't refer him to Family Stabilization (which I believe would have done this family a world of good)  Wraparound services seem to be part of the Rosie D settlement, but not SB 2518.  Still, this bill would have made life easier for this family and for Kenny (who, by the way, is back in school now and seems to be doing well).  It is a great step forward in the provision of comprehensive mental health services to our children.  They deserve nothing less.

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