Monday, February 28, 2011

From SAMSHA: A reminder that policies have consequences.

SAMSHA sent me a reminder today, that, in two months, it will with be Children's Mental Health Month. They included this graph, from some research out of ASPE in the last administration. In the accompanying report, it was pointed out that the way to prevent this from happening was to strengthen the social network around parents and children. So why are budget cuts in the current House Continuing Resolution targeting programs that support that very network? Full report available here.

"Young children exposed to five or more significant adversities in the first 3 years of childhood face a 76 percent likelihood of having one or more delays in their cognitive, language, or emotional development. The likelihood of delay increases in nearly a straight line with the number of risks.1

However, research has shown that caregivers can buffer the impact of stress and promote better outcomes for children even under stressful times when the following Strengthening Families Protective Factors2 are present:

  • Parental resilience
  • Social connections
  • Knowledge of parenting and child development
  • Concrete support in times of need
  • Social and emotional competence of children

Friday, February 25, 2011

Need help navigating the system? Sometimes a kid needs a lawyer.

50 years ago, Leonard Bernstein captured the essential dilemma of the juvenile justice system in the song "Office Krupke", where a youth on the street goes from police officer to social worker to psychiatrist to judge in an eternal circle of ineffective care. Health Law Advocates has been trying to break that circle through the Mental Health Guardian Ad Litum program. Can be useful sometimes to have someone looking for a way out. (By the way, doesn't Lenny look great on YouTube? Really miss having him around...)


HLA and Children's Mental Health

One of HLA's leading initiatives is our Children's Mental Health Access Project (CMHAP). Since we launched this initiative, HLA's work in this area has helped scores of families to overcome obstacles to securing diagnoses, treatment, and follow-up care for their children with unmet mental health needs.

A major component of HLA's CMHAP is our Mental Health Guardian Ad Litem (GAL) program which focuses on helping juvenile court-involved children who need mental health care. HLA attorneys are appointed by Juvenile Court Justices in select locations as Mental Health GAL for children in court who are falling through the cracks of the mental health system. The Mental Health GAL's role is to identify the child's unmet mental health needs, advocate on behalf of the child's interests and recommend judicial actions.

Numerous studies have measured a high incidence of mental illness among children in the juvenile justice system. The enormous cost of not diagnosing and treating mental illness in these children is apparent. Children who do not get the care they need are at greater risk of entering and remaining in the juvenile detention system and eventually the adult justice system, resulting in substantial social and economic costs to families, communities, and public agencies.

HLA's Mental Health GAL Project is currently supported by the Klarman Family Foundation and has received past support from the Jesse B. Cox Charitable Lead Trust, the Health Foundation of Central Massachusetts, the Nord Family Foundation and the Massachusetts Bar Foundation.

Thursday, February 24, 2011

Reforming CHINS is not easy

I guess it is harder to reform CHINS than it looked. Secretary Bigby sent this out today.

Letter from Secretary Bigby

Sent:Wednesday, February 23, 2011 7:50 PM

Subject: A Message from Secretary Bigby

Dear Colleagues,

I am writing to keep you informed and engaged in an exciting effort to strengthen the many services and supports we provide to children, youth and families. Since I became Secretary, I have heard from a diverse range of stakeholders - including families we serve, agency staff and advocates - about the need for a more integrated and coordinated system of services. I have also heard the need for services that strengthen families through a respectful approach that is holistic, responsive to each family's unique needs, and community-focused. In numerous forums, including the Human Service forums hosted by Governor Patrick in 2009 and 2010 and the recent Children's League Advocacy Day at the State House, advocates and stakeholders encouraged the Patrick- Murray Administration to address the "current maze of agencies" to make the service delivery system more closely coordinated and with a single access point for families seeking services.

Governor Patrick has heard the repeated requests from numerous sectors of the child-serving community to strengthen service access and coordination and has asked EOHHS to engage with a broad range of stakeholders to define how to reform the Commonwealth's services for children and families. We began discussions with agencies and with some stakeholders. In the coming weeks we will continue our discussion about how we can together streamline and strengthen the services and supports we offer to children, youth and families. We look forward to engaging in a thorough and thoughtful series of discussions about our ideas for improving service delivery. State employees, so many of whom are on the "front lines" of service delivery, will play an integral role as we refine our plans and we plan to engage Union leadership throughout this process. I welcome your input and feedback and will be in touch with you again soon with more information about this process.

In the meantime, thank you for the work you do each and every day on behalf of all of our consumers and for your commitment to working with us to strengthen the services and supports we offer.

JudyAnn Bigby, M.D.


JudyAnn Bigby, M.D.

Secretary, Executive Office of Health and Human Services

One Ashburton Place, Suite 1109

Boston, MA 02108

617 573-1800

Assistant: Mary Skahen (

Friday, February 18, 2011

Family Perspective is Worthwhile.

Too much interesting stuff going on in the world.



Save the Date: Friday, February 18th, 2011, from 11:00a.m. to 12:30p.m. Eastern Time.

Topic: The Integration of Mental Health and Primary Care ~ The Family Perspective

NAMI will be on the February Children’s Conference Call with Dr. Duckworth to discuss the integration of primary care and mental health from the perspective of families. We conducted a national survey on the family experience with primary care physicians and staff and will share some of the survey results during the call. We will also discuss the role primary care physicians can play in the early identification and intervention of mental illness.

Friday children’s conference calls with Dr. Ken Duckworth, NAMI’s medical director and a child and adolescent psychiatrist, take place on the third Friday of every month. The calls are toll free and are scheduled from 11:00 a.m. – 12:30 p.m. E.T. To access the toll-free call, please dial 1-888-858-6021; access number 309918#. We hope that you will join us!

Thursday, February 17, 2011

This is not good for children.

Wraparound requires that you have services to network with. The current Federal budget debate puts that at risk, as outlined in the letter I got today from Michael Petit:

Dear David,

This has been a major week for the future of childrens programs. We want to give you a breakdown of what is being debated and tell you what you can do to fight the wrong decisions many in Congress want to make.


On October 1st of last year, the federal fiscal year 2011 began. The Congress did not pass a budget funding government programs. Instead they passed what is known as a continuing resolution that funds programs at essentially the same level they were in 2010. This resolution will expire on March 4th. Congress needs to pass final legislation that will fund the government until September 30th of this year or at some point government could "shutdown.' The fiscal year for 2012 will begin on October 1st of this year.

What the Congress is Currently Considering

The House of Representatives recently proposed a series of cuts to the budget for this year. Last week we told you about how they proposed $32 billion in cuts including to the Maternal and Child Health Block Grant, the Women, Infants, and Children (WIC) program, community health centers, poison control centers, and other childrens programs. This was not enough for some members of the House, particularly those who associate with the Tea Party movement. On Friday night, a day and time known by government officials as the best to release information that they know will get the least amount of media coverage, the Appropriations Committee offered an additional $42 billion in cuts. These include

Head Start - $1 billion (15%) cut

Community Health Centers - $1 billion cut

Community Services Block Grant - $341 million cut

Low Income Home Energy Assistance contingency fund - $390 million cut

Title I (K-12 education for low-income students) - $693.5 million cut

IDEA (special education) grants to states - $560 million cut

Special Supplemental Nutrition Program for Women, Infants, & Children (WIC) - $747 million cut

21st Century Community Learning Centers (after school programs) - $100 million cut

Maternal and Child Health Block Grant - $50 million cut

Child Care Development Block Grant - $39 million cut

Many other children's programs will be eliminated entirely. Some examples include:

Teen Pregnancy Prevention Grants

Mentoring Children of Prisoners

Even Start

Striving Readers

High School Graduation Initiative

Student Aid for higher education

LEAP program (for low-income college students)

The House could include even more cuts as they debate this resolution.

These cuts are wrong on many levels. They harm children at a vulnerable time in their development. The economy remains in recession, and an all-time record number of children (14,567,000) currently live in poverty. Cuts like this would mean that 368,000 low income 3-and 4-year olds would lose the education and nutrition program they receive at their Head Start center. The education cuts, along with others being made in states, would leave thousands of teachers out of jobs this year. Many in Washington say these cuts are needed to reduce the deficit. However, these cuts would take only 2% off this years projected deficit. So essentially, these cuts harm children and dont solve Americas fiscal challenges.

What You Can Do

Contact your member of the House and Senators and tell them you oppose these cuts and why. They will listen to you. The original House proposal included a $210 million cut to the Maternal and Child Block Grant. When they heard from people opposed to this, the Republicans reduced their cut to $50 million. Many lawmakers are not fully supportive of all these cuts. When they reduce these cuts, they are showing just how much discomfort they have. Click here to contact your representatives. Some suggestions when you get hold of someone in their office:

Tell them that Congress needs to start budgeting like real families and put our nation's kids first! Please stop these harmful proposed cuts to programs that are essential for our nation's economic future.

Remind them that scientific research and leading economists have said for years that investing in children is one of the smartest investments we can make. We need more investments in the health, safety, and education of children, not mindless cuts.

Ask them what they would say to the 4-year-old in their district or state who is forced out from his or her Head Start program.

Let us know what they say.

What Happens Next

Even if the House of Representatives passes all of these cuts to the budget for this year, the Senate has their say as well. Senator Daniel Inouye of Hawaii, the chairman of the Senate Appropriations Committee, has slammed these cuts, saying they would impede the federal government from completing even its most core functions. President Obama has threatened to veto these cuts. This debate will continue throughout the year.

At some point, Congress will begin debating the budget for next year. This week, President Obama released his budget for 2012. Overall, it contains a small increase to childrens programs. Not all programs receive an increase. The President proposed cuts in juvenile justice, heating assistance for low-income families, and community service programs. He makes up for this somewhat with increases in Head Start, afterschool programs, child nutrition, child health, and education programs. We will let you know much more about this proposal for next year, but the main business in Washington is to fight the cuts House members want to make to childrens programs, right now.

Michael Petit


Every Child Matters Education Fund

Wednesday, February 16, 2011

Mental Health Parity is Still Confusing

Still trying to understand Mental Health Parity? Me too. These might help:

Free Webinars for Consumers: The Mental Health Parity and Addiction Equity Act (MHPAEA)

SAMHSA's Partners for Recovery Initiative invites you to two free webinars on the new Federal parity law.

Parity 101 | February 17, 2011 | 1 to 2 p.m. Eastern Time

The webinar will provide a general overview of MHPAEA and the recently released Interim Final Rule. The webinar, which is directed to consumers, will be presented by health policy experts from the Legal Action Center.

Register for Parity 101 Webinar

Parity 201 | March 10, 2011 | 1 to 2 p.m. Eastern Time

The webinar, designed for states and providers, includes a detailed discussion about implementation of MHPAEA. This discussion will provide details on state-level implementation efforts, interplay between the Federal parity law and state parity laws, and anticipated additional pieces of regulatory guidance.

Register for Parity 201 Webinar

Tuesday, February 15, 2011

This looked interesting. Wish I had time to listen in.

TeenScreen National Center Webinar
Managing ADHD in Children and Adolescents:A Clinical Update
Wednesday, February 23, 2011

ADHD remains the most prevalent and challenging of behavioral disorders in school-aged children. With research showing that children with ADHD face increased risks of major depression and suicidal ideation in adolescence, clinicians are confronting both the immediate and potentially long-term burdens of a disease that can impact a patient’s emotional, social and academic life.

Lawrence Greenhill, MD, is a child and adolescent psychiatrist and a leading researcher on the treatment of ADHD. The Ruane Professor of Clinical Psychiatry at Columbia University and current President of the American Academy of Child and Adolescent Psychiatry, Dr. Greenhill will discuss the latest research and clinical advances in the treatment and management of ADHD.

Click here to register

Click here for event details.

Monday, February 7, 2011

Comments on the WBUR series.

I promised comments, but, like most of America, I watched the Super Bowl and ate chilli last night (good vegetarian chilli with a nice sourdough bread and cheddar cheese atop, Moosewood recipe). This morning, I woke up to WBUR's comments and though that I might start by reflecting on those, which you can read here.
A few thoughts:
1) Stigma really does exist. Lots and lots of people do not seem to believe that mental illness is as common as it seems to be, and that there is value in blaming parents, Ben Spock, liberals, modern society, the internet, vaccines, toxins and all manner of things for its existence. Their conclusion is that, if we just took those things away, it would get better. Much more likely is that mental illness does exist (the brain is the most complicated organ we've got; why should that work better than our heart or liver?) and that we are seeing more problems now because people are surviving childhood diseases that may have been harder on those with mental illness in the past, and that we are asking the brain to function in a way that we have not asked it to do in the past. In any event, how a brain gets messed up is useful in prevention work; what to do after the fact is actually a separate issue. People should be kind to those trying to cope with the aftermath, many of them are, but a lot of the ones that aren't wrote into WBUR last week (and perhaps went back to their Scientology meetings afterwards). The fight is not over, just because we have mental health parity now.
2) There is a disparity between care for the poor and the middle class (and the rich): But it is not what you think. The rich can pay cash for a child psychiatrist like Dr. Edna in Mad Men, who will talk with there child, develop a plan for treatment that involves therapy with the judicious use of medication, and sometimes treatment in ranches in New Mexico. The poor are locked into Medicaid, which is held to an EPSDT standard for children: If we find it, it must be treated. This allows the poor in States with good advocates to do things like the Rosie D. lawsuit, and to get Medicaid to cover a variety of what are called "wraparound" services, things that do more for kids than give them medications with reckless abandon. Granted, they still do: there are several studies showing that rates of medication in Medicaid patients are high. But it is usually the case that meds in Medicaid, at least in Massachusetts, are tied to some sort of therapy and the CBHI is working hard to get the children with serious emotional disturbances into some sort of coordinated care. The vast majority of us, however, are in commercial plans, which are not held to the EPSDT standard. Those kids often find it easier to get medications than to get therapy, and may actually be getting care that is less comprehensive than either the rich or the poor, a problem that is augmented because the parents are working, and don't that the time or resources to advocate for their child that are available to those who are either rich or poor.
3) What to do about this is a political decision. So, do you upgrade the middle class to at least the level of support given through Medicaid? Or to do take down the poor to the level of the middle class? That is a classic politic dilemma, and fits well into the current discussions about the appropriate role of government. I would argue that to cut services to the poor guarantees increase cost in unemployment, disability and incarceration in the future, and is a "penny-wise, pound-foolish" strategy, but others would certainly disagree.
4) Treatment of mental health problems in childhood is complicated. While the new services offered by the CBHI are great, they reflect that complexity, and will require much care coordination if they are to be used effectively.

Good series. You should listen to it.
Good chilli. You should eat it.

Saturday, February 5, 2011

Back to the Legislature: Making it Better

I meant to listen to the WBUR series, I really did. I will do so this weekend, and pour forth a spate of commentary. In the meantime, the Campaign does have some good ideas going forward:

As the 2011-2012 legislative session commences, the Children’s Mental Health Campaign (CMHC) continues advocating to improve the system of care for children with mental illness and their families. Please click HERE today to contact your State Senator and State Representative and ask them to sign-on as co-sponsors of CMHC’s 2011-2012 legislative session priorities:

Coordination of Children’s Mental Health Care

Lead Sponsors: Senator Steven A. Tolman and Representative Ruth B. Balser

This provision requires commercial insurance companies to reimburse licensed children’s mental health clinicians for time spent in consultation with families, teachers, pediatricians, day-care providers and other adults who regularly interact with the child in order to make a diagnosis or to formulate or implement a treatment plan.

Families and Children Engaged in Services (FACES)

Lead Sponsors: Senator Karen E. Spilka and Representative Paul J. Donato

The Child in Need of Services (CHINS) system is intended to provide assistance to children and families when the child is habitually truant, runs away from home or refuses to obey the lawful and reasonable rules of their parents or their school. This provision transforms the current juvenile justice based system in to one which is community based.

Proportional Payments of the MA Child Psychiatric Access Project

Lead Sponsors: Senator Jennifer L. Flanagan and Representative Ruth B. Balser

The MA Child Psychiatric Access Project (MCPAP) provides primary care providers, who are on the front lines in diagnosing and treating mental health disorders, access to mental health consultations with a team comprised of child psychiatrists, psychologists and/or social workers. This provision requires commercial insurers to contribute to the funding of this program at a rate equal to the participation of their membership.

For more information about these bills please visit the CMHC's legislative priorities page at

We need your help turning these important bills into laws. Thank you for your continued support and advocacy on behalf of the Commonwealth's most vulnerable children!

Thank you,

Erin G. Bradley

CMHC Coordinator

Wednesday, February 2, 2011

Reflecting on Part 1: WBUR's series on Mental Health Treatment

First, this is really well done, in depth, radio journalism. You should listen to this here, if you haven't already. It tells the story of a young man who has a story similar to many that I have seen over the years, who has had some sort of mental health problem, has accessed our system (in a manner, to be clear, that most of the country cannot) and is entering adulthood confused about his diagnosis, his need for treatment and his prognosis going forward. He (and implicitly the reporter) imply that it really shouldn't be so hard. What is it about? A few themes, that you may have heard before.
1) Behavioral/psychiatric problems are hard to diagnose, in part because diagnosis is based on clinical impression. This family had many reports; with many diagnoses and many recommendations and it made them confused.
2) Stigma lives. A youth with mental health, who develops substance abuse problems suddenly has to find a whole new treatment system. Why? Read the comments that people have left on the website. The obsession with blame and fault is impressive.
3) Primary care wasn't helpful. This family really would have benefited from a primary care doc who stayed with them throughout the journey. Kind of sad that they had to keep looking.
4) Treatment works. Sort of. Sometimes. The young man in the story was not a big fan of the many medications that he has taken over the years, although, in the end, he conceded that they may have been helpful. A long term relationship with a consistent provider may have been helpful.

More tomorrow.

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