Addressing the Mental Health Needs of DC’s Children

Addressing the Mental Health
Needs of DC’s Children
public health issue, as roughly 15% of children in the
U.S. experience a mental disorder each year (CDC,
2013) and half of all adults with a mental health
disorder had symptoms by the age of 14 (Kessler, 2005).
Factors affecting children’s mental health start in infancy
and young childhood, during the early beginnings of
brain and self-regulation development, and continue
throughout childhood and adolescence (Bayer, 2011).
Recognizing the different risk factors and signs of a
mental health issue at each development stage is the first
step in combatting these often chronic conditions.
While many of these issues can be identified early, few
children receive the subsequent services that they
require (McCue Horwitz, 2012). DC’s children are
particularly underserved, especially those enrolled in
Medicaid, as at least half of those children don’t receive
the treatment their mental health diagnosis requires
(DC Action for Children, 2012).
Identifying Risk Factors
Risk factors for children’s mental health apply to children
of all ages, including infancy (Bolten, 2013). Identifying
and mitigating these risks is a critical component of
prevention. Some risk factors that apply to children of
all ages include the child’s poor physical health; younger
and less educated mothers; negative family dynamics,
and demographics (i.e. low socioeconomic status) and
community context (i.e. lack of accessible resources).
While some children may only have one or two risk
factors, many will have several. It is important to note
that the cumulative risk effect is more important in
determining psychological problems than one single
stressor, no matter its magnitude (Halpern, 2004).
Mental Health and Children with Special
Health Care Needs (CSHCN)
Studies suggest that children with special health care
needs (CSHCN) have a greater incidence of emotional,
behavioral, and social adjustment problems (EBDP)
than children without chronic conditions, often due to
disease-related stress, frustration with medical
management, social isolation from peers, and despair at
the awareness of limitations or differences from others
(Tang, 2008). Additionally, urban community stressors,
such as poverty and crime; race; and the child’s health
status are also significantly correlated with mental health
problems among CSHCN (VanLandeghem, 2009). In
fact, 25% of parents of CSHCN report that their child
has a mental health need that is attributed to their
condition. In particular, mental health needs are more
frequent in CSHCN that have EBDP, as 67% of parents
of children with EBDP reported a mental health
concern (Inkelas, 2007). Additionally, children with
only Medicaid managed care are 1.8 times more likely
to have an unmet mental health needs (Tang, 2008). It
is also important to recognize that parents of CSHCN
may have mental health needs of their own due to the
stresses of navigating the medical field and providing
more extensive care than required by children generally.
What Can I do to Address the Mental
Health Needs of Children for Whom
I Provide Services?
If you are a primary care provider:
Primary care offers an underutilized potential for
identifying and treating children’s mental health needs
(Asarnow, 2002). Compared with adults, children with
mental health concerns are often brought by their
parents to their primary care provider (PCP) rather than
This project was funded by the Government of the District of Columbia,
Department of Health, Community Health Administration
Grant No. CHA.CPPW.GU.062012
Government of the
Disctict of Columbia
Vincent C. Gray, Mayor
to a psychiatric specialist (Olfson, 2014). Fifteen to
20% of children and adolescents seen in primary care
have a behavioral health disorder, yet only one in five
children are identified by their pediatricians and even
fewer receive mental health services (Cassidy, 1998).
PCPs can efficiently and appropriately help these
children by applying chronic care principles, similar
to those employed for treating asthma or diabetes, to
children with mental health needs. The American
Academy of Pediatrics (AAP) endorses the chronic
care model, which includes supporting child and
family self-management, defining the roles of the
practice, providing support tools for the family, and
strengthening the clinical referral systems (Foy, 2010).
In DC, the Department of Health and the
Administration on Community Health (the state Title
V agency) has funded the DC Collaborative for Mental
Health in Pediatric Primary Care, an organization
including providers, researchers, and respresentatives
from key agencies, local academic universities and
medical centers, community advocacy organizations,
and the state chapter of the AAP. The DC Collaborative
aims to improve integration of mental health in
pediatric primary care through assessment of
community needs and capacities, planning, and policy
development. Additionally, the DC Department of
Health Care Finance (DHCF) indicates that Medicaid
Managed Care Organizations (MCO) as part of the
EPSDT requirements are required to ensure annual
mental health screenings of children and youth by their
Primary Care Provider (PCP).
How Can I Screen for Mental
and Behavioral Health Issues?
Standardized screening tools are useful to PCPs. In fact,
studies indicate that the use of formal tools is superior
to subjective surveillance in detecting behavioral health
problems in primary care (Simonian, 2001). There are
many screening tools available, however tools should be
developmentally appropriate and clinically useful; brief;
easy to administer, score, and analyze; and should have
acceptable reliability and validity (Carter, 2010). While
screening tools are emphasized in practice, it is important
for PCPs to recognize that screening may lead to overidentification, therefore clinical judgment, additional
screenings, and further triage will be necessary for an
accurate diagnosis (Asarnow, 2002).
It is also important to screen for physical or
environmental conditions that could affect development
(DC Health Check, Validated Screening Tools for
Middle Childhood, n.d.):
• Lead hazards (older homes, recently renovated older
homes, lead-based paint, lead dust, pica, drinking
water, certain ceramic ware);
• Anemia risks (low iron intake, history of irondeficiency anemia, restrictive or inadequate diet); and
• Signs of neglect, physical or sexual abuse,
malnutrition, and deprivation
Cultural Competency in Screening
Almost all developmental tests have at least some element
of cultural bias. It is important for testers to be cognizant
this fact and be sensitive and well-informed about families
with different cultures or practices. Those administering
screening tools should be knowledgeable about the
family’s culture and the language of the child, be respectful
of the family’s cultural values, and ensure that all tests
and evaluation materials are given in the native language
of the child (DC Health Check, Validated Screening
Tools for Infancy, n.d.) There are varying degrees of
stigma related to mental and behavioral health problems
across cultures. Understanding these concerns is vital to
helping families take steps to address problems that may
be identified in the screening process. An excellent
resource on cultural competence in screening is
available at
While it focuses on screening for autism, the principles
apply to any type of mental health, behavioral or
developmental screening.
Are screening tools effective?—Myths About
Screening Tools (CDC, 2014)
MYTH 1. There are no adequate screening tools
for preschoolers.
Although this may have been true decades
ago, today most screening tools have
sensitivity and specificities greater than 70%.
Myth 2. A great deal of training is needed to
administer screening correctly.
Training requirements are not extensive for
most screening tools, and many can be
administered by paraprofessionals.
Myth 3. Screening takes a lot of time.
Many screening instruments take less than
15 minutes to administer, and some require
only about 2 minutes of professional time.
Myth 4. Tools that incorporate information from the
parents are not valid.
Parents’ concerns are generally valid and are
predictive of developmental delays. Research
shows parental concerns detect 70-80% of
children with disabilities.
What Screening Tools Should I Use?
DC Health Check Training and Resource Center
provides information about validated screening tools
with links to the tools.
After Identifying a Problem
in Screening—What Next?
Many common behavioral problems can be
effectively addressed within the primary care setting.
Bright Futures in Practice: Mental Health Volume I
contains a section called Bridges with practical and
effective interventions within the primary care setting
for common mental health and behavioral issues.
However effective referral for additional evaluation and
treatment is also essential. The DC Collaborative for
Mental Health in Pediatric Primary Care has created
the Child and Adolescent Resource Guide
mental-health-guide.html which will be updated with
new information. The guide provides information about
services by type and by age/stage of the child. It also
provides additional resources for primary care providers
about addressing the mental and behavioral health
needs of the children they serve.
What if I am Not a Primary Care Provider?
Others who provide service to children and their
families can play an important role in supporting
children’s mental and behavioral health. Learn about
typical child mental and behavioral development and
how to recognize risk factors and potential problems.
An excellent resource for this is Bright Futures in
Practice: Mental Health that presents information about
childhood mental health within a developmental
context and offers a tool kit for professionals and
families for use in screening, care management, and
health education available in PDF format at
Raise concerns with families and seek their perspective
on their child’s development, even if you are addressing
other needs in your service provision. Encourage families
to share their concerns with their child’s primary care
provider and to ask for mental and behavioral health
screening within their medical homes. If you are
working with a child who is receiving services in DC’s
Child and Family Service Agency ask if there has been a
mental health screening completed. Learn about mental
and behavioral resources within the community and
support families in seeking those services.
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