Objectives

  • Identify two components of effective prevention intervention.
  • Given a case example, choose the appropriate mental health prevention intervention for one of the eight developmental stages.
  • Identify four signs of a mental health or behavioral disorder in a child or adolescent.
  • Given a case example, indicate how to evaluate a child or adolescent with a mental, emotional, or behavioral disorder.
  • Identify when a child or adolescent with a mental, emotional, or behavioral disorder should be referred.

Prevention Intervention

An increasing number of mental, emotional, and behavioral problems in young people are in fact preventable according to Preventing Mental, Emotional, and Behavioral Disorders Among Young People (NRC-IOM, 2009). The report builds upon the highly valued predecessor, Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research (IOM, 1994). Researchers of the 2009 report argue that, “effectively applying the evidence-based prevention interventions at hand could potentially save billions of dollars in associated costs by avoiding or tempering these disorders in many individuals.”

According to Knitzer & Lefkowitz (as cited in NCCBH, n.d.), “factors that predict mental health problems can be identified in the early years, with children and youth from low-income households at increased risk for mental health problems.” The key to most intervention approaches is to identify the biological, psychological, and social factors that may increase a child’s or adolescent’s risk.

Effective prevention includes:

Interventions are designed to address differential risk and protective factors prominent in a particular developmental stage or the emergence of symptoms that tend to occur at different ages. The Committee on Prevention of Mental Disorders and Substance Abuse among Children, Youth and Young Adults has identified eight developmental phases in a young person’s life offering variable opportunities for intervention.

Interventions by Developmental Phase

Health-care providers could make a substantial systematic contribution to prevention of mental, emotional and behavioral disorders. However, “realizing this potential will require transformational changes on the part of training institutions, professional societies, regulatory bodies, and funders” (NRC-IOM, 2009). To learn more about prevention interventions, access the 2009 NRC-IOM report here.

Recognizing a Mental Health or Behavioral Disorder in a Child or Adolescent

Mental Health Screening is part of the Texas Health Steps Comprehensive Health Screening - Texas Health Steps Medical Checkup Periodicity Schedule for Infants, Children, and Adolescents. Comprehensive Health Screening is defined as: both objective screening with use of standardized procedures or screening tools and subjective screening of those components when a standardized procedure or screening tool is not required. Mental Health Screening is considered subjective screening and is appropriate unless the provider determines an objective screen or test is necessary. Refer to the 2010 Texas Medicaid Provider Procedure Manual (TMPPM) for further detail.

According to the National Mental Health Information Center (NMHIC), children and adolescents with mental health issues need to get help as soon as possible. “Treating cases early could prevent enormous disability, before the illness becomes more severe, and before co-occurring mental illnesses develop, which only become more difficult to treat as they accumulate” (Kessler et al., 2005).

A variety of signs may point to mental health disorders or serious emotional disturbances in children or adolescents. Pay attention if a child or adolescent has any of the warning signs listed below.

A child or adolescent is troubled by feeling:

A child or adolescent experiences big changes, such as:

A child or adolescent experiences:

A child or adolescent behaves in ways that cause problems, such as:

For more information about high-risk behaviors, enroll in the Texas Health Steps online educational module Identifying Children and Teens with High-Risk Behavior.

How to Evaluate a Child or Adolescent

Evaluating the child or adolescent in the context of his or her family, school, community, and culture is central to all child and adolescent psychiatric assessment. For most children and adolescents, this entails at minimum gathering information about the child’s or adolescent’s family, school functioning and medical history. Children and adolescents with serious emotional disturbance who are served in community systems of care have been shown to have high rates of co-morbidity, psychosocial adversity and involvement with multiple agencies, and they are at highest risk for placement in restrictive settings.

In such cases, clinical assessment requires an even more comprehensive approach and should incorporate a broad social ecological framework, taking into account a multiplicity of environmental and systems factors. The social ecological perspective views the child or adolescent as embedded within interconnected systems, including the family system (and the extended family) and the extra familial systems, such as school, work, peers, primary health care; and the larger community and cultural institutions that are part of the child or adolescent and family’s life experience, such as religious institutions.

Systemic issues (e.g., legal, social, financial) that affect care are also part of the child’s or adolescent’s ecological system. Ecologically targeted interventions may involve addressing barriers to care (e.g., providing home-based services or transporting the child or adolescent to appointments) or accessing strengths and resources in the child’s or adolescent’s natural environment that can promote positive change. For example, identification of a helpful adult who is already present in the child’s or adolescent’s natural environment and may become a formal mentor or provide part time employment can be a potent intervention.

Because children and adolescents are involved in many systems, it is essential that adequate time be allotted in the evaluative process to gather ancillary data and communicate with other providers, in addition to having adequate time to interview the child or adolescent and family.

When To Refer

When considering whether a child or adolescent would benefit from seeing a mental health professional, it is important to not just focus on individual warning signs and symptoms as previously discussed, but to look at the intensity, frequency and persistence of the presenting symptoms and the degree to which they interfere with the child’s or adolescent’s functioning.

Criteria for Referral

The AACAP’s “When to Seek Referral or Consultation With a Child and Adolescent Psychiatrist” contains recommendations to guide pediatricians, family practitioners, and other primary care providers in determining if intervention by a child and adolescent psychiatrist may be necessary.

Types of referrals to consider include:

When considering whether to refer, the referring practitioner should consider the following criteria.
When a child or adolescent:

It is the primary care provider’s responsibility to follow up with families and work with others treating the child or adolescent to help maintain consistency of treatment.

Medicaid Requirements for Specialist Referrals and Telephone Consultations

When a provider performing a checkup determines that a referral for diagnosis or treatment is necessary for a condition found during the medical checkup, the provider must discuss that information with the parents/guardians. Referrals must be made to providers qualified to perform the necessary diagnosis or treatment services. If the performing provider is competent to treat the condition found, a referral elsewhere is not necessary, unless it is to the primary care provider to assure continuity of care. Medicaid managed care clients must be referred to their designated primary care provider for further treatment or referral.

Providers needing assistance to find a specialist that accepts clients with Medicaid coverage can call the Texas Health Steps Hotline at 1-877-847-8377 or they can find one using the Online Provider Lookup on the TMHP website. To learn more about Medicaid coverage, including additional referrals consult the “Referrals for Medicaid-Covered Services” section 6.1.5 in the Children Services Handbook of the Texas Medicaid Providers Procedure Manual, 2010 Online Edition.

Under the Comprehensive Care Program (CCP), primary care providers may receive reimbursement for telephone consultations with a psychiatric specialist as part of clinician-directed care plan oversight. In addition, the specialist may receive reimbursement for providing the telephone consult. Texas Medicaid defines a telephone consultation as the process where the specialist receives a telephone call from the clinician providing the medical home and during which the specialist provides advice or a referral to a more appropriate provider. Reimbursable telephone conferences must be at least 15 minutes long, and require prior authorization. The medical home provider must use the CCP Prior Authorization Request for Non-Face-to-Face Clinician-Directed Care Coordination Services form.

More information on telephone consultations is available online in Texas Medicaid Bulletin, No, 220.

For more information about Medicaid Children’s Services and CCP, enroll in the Texas Health Steps provider education module, Medicaid Children’s Services.

Always seek an urgent evaluation if you believe the child or adolescent is at immediate risk of harm to themselves or others or there has been an acute deterioration of thinking, emotions, or behavior that could place the child or adolescent at risk for harm to him or herself or others.

As stated in Section 1: Recognizing Emergency Situations, the Texas Medicaid Provider Procedure Manual states that whenever a mental health crisis is suspected, every effort must be made to secure a prompt mental health evaluation and any medically necessary treatment for the client. An emergency mental health referral for evaluation and/or treatment must always be made when any of the following are identified during a mental health screening:

It is also important to note if guns or other weapons are kept in the home of the child or adolescent being evaluated, as access to these weapons may increase the risk of violent or dangerous behavior.

For more information about conducting a mental health screen, refer to the Texas Health Steps Mental Health Screening module.

Where to Refer

Providers should have ready access to local agencies, services, and specialists both for themselves and to help families during this time and moving forward. Additionally, it is the provider’s responsibility to follow up with families and work with others treating the child or adolescent to help maintain consistency of treatment. This will be discussed further in Section 4. The following are local resources.

Texas Programs Serving Children and Adolescents with Mental Health Needs

Health and Human Services Commission (HHSC) has a major role in the funding and oversight of publicly funded mental health care in Texas. It funds health-care coverage for mental health services for children and adolescents through its operation of the Medicaid and CHIP programs. In its coordination and oversight role, the HHSC also provides policy direction and leadership for two major programs providing local coordination of services for children and adolescents with special needs: the Texas Integrated Funding Initiative (TIFI) and the Community Resource Coordination Groups (CRCG).

Within DSHS, the Mental Health and Substance Abuse Division is designated as the Mental Health Authority for the state and oversees the mental health system. Specifically, Community Mental Health Services for adults, children and adolescents are administered through 37 Local Mental Health Authorities (LMHAs) and one Behavioral Health Organization (BHO). In most areas of the state, the LMHA is also a Community Mental Health Mental Retardation Center (CMHMRC). Services provided by CMHMRCs throughout the state include the full array of Resiliency and Disease Management Services, which include counseling, rehabilitative services, assertive community treatment, case management, supported housing and employment, and medication management. The exception to CMHMRC model of service delivery is the NorthSTAR BHO, which provides mental health and substance abuse services to indigent members and most Medicaid recipients within seven counties surrounding the Dallas area. NorthSTAR is a Medicaid Managed Care Behavioral Health Care “Carve Out” with a Local Behavioral Health Authority.

Services are managed by a licensed Health Maintenance Organization (HMO) under direct contract with DSHS. Through the DSHS contract and local oversight of the local behavioral health authority, the contracted HMO supports the network development of a wide array of individual, group and facility based providers, performs utilization management functions, quality management, customer service, and claims adjudication. The contractually required service array includes the same Resiliency and Disease Management services required of the CMHMRCs.

Texas Medicaid Program

Medicaid is a joint federal-state program that pays for health-care expenses for very low-income families and disabled adults. Medicaid also covers specialized services, such as mental health rehabilitation and case management, to Medicaid recipients.

The Medicaid program provides the following mental health services: All children and adolescents enrolled in Medicaid are entitled to receive mental health services, including assessment, outpatient treatment, medication, emergency care, and inpatient psychiatric hospitalization.

Texas Medicaid services are managed through a variety of programs including managed care programs (STAR, STAR-Plus, Primary Care Case Management, and the more traditional fee-for-service programs).

Children’s Health Insurance Program (CHIP)

CHIP is designed for low-income families who earn too much money to qualify for Medicaid and do not otherwise have access to health insurance.

The CHIP mental health and substance abuse benefits include coverage for inpatient and outpatient treatment:

Children’s and Adolescents’ Mental Health Services

The following are some of the services that DSHS requires all local mental health authorities to provide:

Providers with children or adolescents on Medicaid: Children or adolescents on Medicaid who are diagnosed as severely emotionally disturbed and qualify for services cannot be placed on a waiting list. Contact your local mental health authority for more information.

As facilities may be scarce, providers should identify resources in their service area. This will help expedite treatment should a patient crisis arise.

Click the following link to view more information about DSHS Children’s Mental Health Services.

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