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Psychiatry
What State Budget Cuts Mean for the Most Troubled Children
Children's psychiatric treatment: pay now or pay more later.
Posted March 30, 2011
By Josephine Johnston and Erik Parens
If your child ends up on 12 North, the Children's Psychiatry Unit at Stony Brook University Hospital, he has probably been diagnosed with one, or many, serious mental disorders. He (or she) has likely been prescribed myriad medications. School accommodations have failed to help and he may have been expelled. Maybe he assaulted his teacher or had a meltdown so bad you had to call the police. Maybe he threatened to kill himself because you were trying to get him to school and he was refusing to go. Perhaps he was placed in four point restraints in the emergency room, and sedated. The day you had to turn to 12 North was one of the worst days of your life.
But it would have been even worse if 12 North didn't exist, which is exactly what was threatened by New York Governor Andrew Cuomo's much protested budget.
Study after study at the national level shows that our health care system is failing to adequately help children with serious emotional and behavioral disorders. These children either do not access services at all, or they receive piecemeal, inconsistent, hurried care, with drug treatment as the default option.
A 2006 study of children and adults treated with antidepressants reported that just under 15 percent received recommended follow-up care in the first four weeks of treatment. A 2010 analysis of children treated with antipsychotic medications—drugs supposedly reserved for the most impaired individuals—found that almost 60 percent did not receive a mental health assessment, a psychotherapy visit, or treatment from a psychiatrist during the year they were taking the drugs.
All these findings come at a time when national leaders in child psychiatry are not only calling for careful and therefore time-intensive diagnostic processes, but also careful and therefore time-intensive treatment plans. Such plans combine both medication management and, crucially, psychosocial treatments like parent training, cognitive behavioral therapy, and school-based interventions.
In our three-year project investigating controversies in child psychiatry, we analyzed national debates over diagnostic labels and treatment choices, and we heard again and again about a fragmented mental health care system that constrains the choices of physicians and parents. But, of course, decisions about what is actually available to children and families are often made at the state and local level, as New York's budget debate has so vividly illustrated.
The governor proposed cutting $134.8 million in the 2011-2012 budget from the three SUNY teaching hospitals: Brooklyn, Syracuse, and Stony Brook. Hospitals have to cut somewhere and the leaders of 12 North were told that it was on the list. Were it to close, 85 to 100 seriously ill Long Island children a year would be without an inpatient child psychiatry service committed to providing time-intensive, multidisciplinary care.
Places like 12 North fill a vital role. While the kind of careful diagnosis and treatment recommended by national experts can be achieved by community physicians and therapists on an out-patient basis, for a sizeable number of children, things go so wrong that they need hospitalization. If they are lucky, they end up on a good child psychiatry inpatient unit where their diagnoses are reassessed and their medication regimens are scrutinized and adjusted. Often, they have been misdiagnosed and are taking the wrong medications - and far too many of them.
Gabrielle Carlson, the child psychiatrist who heads 12 North, says that it takes at least a week just to distinguish the effects of psychiatric medications from the symptoms of the disorder they are prescribed to treat. Safely taking a child off three or more medications cannot be done quickly, Carlson stresses. It takes time to experiment with new treatment regimens. The child and his parents must be educated about the particular mental disorder and offered strategies for managing symptoms and avoiding crises. To get all of this right, to give the most distressed and disabled children a real chance of recovering their childhoods, can take 30 to 50 days.
Of course this time-intensive, careful treatment is expensive. But saving money here costs the child, family, and state later. While the cost of in-patient care for a child varies, it comes in at around $1,000 to $3,000 per day (a 30-day stay is typical). Alternatives to in-patient hospital programs, like residential and other specialized out-of-home care, are difficult to access and can cost over $250,000 a year for one child. Parents facing a lack of available, appropriate, and affordable services sometimes take desperate measures.
The Government Accountability Office estimated that in 2001, parents placed more than 12,000 children in the custody of child welfare or juvenile justice in order to get them mental health treatment. Children impaired enough to be hospitalized for psychiatric disorders are at disproportionately high risk of being shuttled among foster care providers, dropping out of school, becoming involved first with the juvenile and eventually the criminal justice systems, and being permanently on Medicaid. This is a case of pay now or pay more later.
In these final days before the budget deadline, Albany lawmakers announced an agreement. While details are still unclear, it seems to restore some funding to state teaching hospitals, including Stony Brook University Hospital. As of this week, Carlson said that the closing of 12 North was off the table, for now. But this is how close some of the most impaired children in New York State just came to being denied the care that national experts insist on.
The Governor's proposed cut to Stony Brook University Hospital was emblematic of the kinds of national, state, and local decisions that seem to save money, but could well cost much more in the long run. Even more distressingly, it was emblematic of a growing willingness to relegate some of our most troubled children to a revolving door of short hospitalizations and medications that don't work or have unacceptable side effects, rather than provide them with the humane care they deserve.
Josephine Johnston, LLB, MBHL, and Erik Parens, PhD, are research scholars at The Hastings Center and the authors of Troubled Children: Diagnosing, Treating and Attending to Context.
