February 2008 - Screening in Massachusetts

Furious Seasons
January 02, 2008
By Philip Dawdy

Massachusetts' Mandatory Mental Health Screening

The State of Massachusetts is embarking on what strikes me as an
excessive social experiment. As of Jan. 1 annual checkups for about
500,000 kids and teens on the state's Medicaid program will have to
include a mental health screening, regardless of whether there's a
reason to suspect mental health issues in the patient or not, reports
the Boston Globe. Doctors are required to do this with each patient,
although parents and children are not legally required to comply. But
then most people are utterly in thrall to doctors and I doubt many would
tell their doctor to back off.

The paper also has an enthusiastic editorial supporting the program.
That's kind of bizarre since the paper has been one of the best at
reporting on just how screwed up mental health care for kids is and how
dangerous some of the treatments are. Perhaps the paper's editorialists
should re-read the paper's series on the Rebecca Riley case and the
bipolar child paradigm.

One of the symptom checklists on the paper's website contains a stunning
array of non-symptom symptoms: teases others, refuses to share, is
fidgety, acts younger than others, daydreams too much, is afraid of new
situations. And so on. Many of these symptoms are hardly indicative of
abnormal behavior or psychology

Could someone please let me know what is the objective standard for
daydreaming?

I object to this mandatory screening for a number of reasons:

1. It represents the kind of governmental intrusion into peoples'
personal lives that Americans should be against.

2. The criteria for diagnosis is not objective. Asking a kid if they are
having less fun is not likely to elicit a reliable response and is
hardly a predictor of mental illness.

3. Pharmaceutical treatments for these conditions are not
well-researched in children and their long-term effects are generally
bad. With anti-depressants in particular there are significant risks of
medication-induced suicidality and extreme agitation.

4. There is not good evidence that pharmaceutical treatments work well
in treating these conditions--the usual 30 percent success rate hardly
inspires confidence--and there is virtually no evidence that these
medications prevent future episodes of a disorder. This is true in
adults, teens and kids.

5. The whole screening paradigm is the brain child of the public health
crowd and pharmaceutical companies, neither of whom are to be trusted.

6. Given that this is limited to Medicaid participants, it unfairly
targets low-income families and ethnic minorities.

I hope parents in Massachusetts are smart enough to refuse to cooperate
with doctors when they start breaking out these screening tests unless
the parent wants their kid screened.

It will be interesting to see where this program goes as the year goes
on and if any resistance breaks out.

As for the Globe, I think the paper's editorial board is out to lunch on
this one. What do readers think?

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About Philip Dawdy / Furious Seasons - excerpted from
http://www.furiousseasons.com/about.html

For the last several years, I have been reporting extensively on mental
health issues, locally and nationally, primarily at Seattle Weekly,
where I was a staff writer until November 2006. In that time, I have
interviewed patients living on the streets, in homeless shelters and in
state mental hospitals, as well as patients leading more ordinary lives.
I have interviewed researchers and doctors great and small.

As far as fancy stuff like journalism awards go, I won awards from the
National Mental Health Association for my newspaper reporting in 2005
and 2006, and have won a half-dozen local and regional awards from the
Society of Professional Journalists for my reporting on mental illness.
In addition, I have won a national award for food writing, and 14 other
SPJ awards for government reporting, investigative reporting, science
reporting, feature writing and religion reporting.

http://www.boston.com/news/local/articles/2007/12/27/mental_screening_for_young_to_begin/?page=1
The Boston Globe
Mental screening for young to begin
Mass. doctors to offer questionnaires for children on Medicaid
By Carey Goldberg
Globe Staff / December 27, 2007

As of Monday, annual checkups for the nearly half a million
Massachusetts children on Medicaid will carry a new requirement: Doctors
must offer simple questionnaires to detect warning signs of possible
mental health problems, from autism in toddlers to depression in teens.

The checklists vary by age but ask questions about children's behavior -
whether they are spending more time alone, seeming to have less fun,
having trouble sleeping - that are designed to trigger discussion
between parents and doctors. The conversations may or may not lead to a
referral to a specialist.

Over the last several years, such questionnaires have increasingly
become the standard of care in pediatric practices, but - spurred by
legal action - Massachusetts is jumping ahead of other states by
requiring the screens for all its young Medicaid recipients.

The new requirement represents "a huge step forward in a direction that
is a national trend," said Dr. Robin Adair, a University of
Massachusetts Medical School pediatrician and screening specialist.

Supporters say the screening can catch issues earlier, before they
develop into hard-to-manage crises.

Skeptics warn that more children could end up on heavy-duty medications
that they don't really need.

"In a more perfect world, screening for mental illness amongst children
would clearly be a good idea," said Dr. John Abramson, a clinical
instructor at Harvard Medical School and author of "Overdosed America."

"But let's look at the realities of the world we live in," he said.
"What happens is that there's a very quick translation of mental health
symptoms into drug treatment."

Others wonder how Massachusetts' overburdened mental health system for
children will handle the new patients the screening is expected to
identify.

Already, children's psychiatrists and psychologists are often
overbooked. Children with serious mental illness sometimes end up stuck
in psychiatric hospitals for lack of mental health services in the
community.

If, as expected, the new screening requirement turns up more children
with mental health problems, "I do think it creates a potential
additional access problem," said Dr. David DeMaso, chief of psychiatry
at Children's Hospital Boston.

The new screening requirement stems from a lawsuit, Rosie D. v. Romney,
that accused the state of falling down on its obligations to poor,
mentally ill children. The federal judge in the case ruled in January
2006 that Massachusetts must improve its care, and the new requirement
is the first step in the state's court-ordered remedy plan.

Families may decline the screening if they wish. If a screen turns up
signs of potential trouble, it is also up to the family whether to
pursue further help and an official diagnosis.
The new requirement applies to the 460,000 children and young adults
covered by MassHealth, the state Medicaid program, at annual checkups
from birth to age 21.

The state's private insurers generally already reimburse children's
doctors for such written screens, and Medicaid will now pay $9.73 to
cover the testing.

The majority of pediatricians still rely on conversational questions
such as "How are you doing in school?" or "Does your child have
friends?" But research shows that written questionnaires are more
accurate at picking up potential problems.

The tests can also home in on children whose problems might otherwise be
missed. According to national estimates, about 10 percent of children
have some sort of significant psycho-social problem, from hyperactivity
to anxiety to stress from living amid domestic violence.

"The earlier we intervene, the more impact we can have on brain
development," DeMaso said.

The screening is not meant to produce a diagnosis, but rather to act as
a "check engine light," calling attention to a potential problem, said
Lisa Lambert, executive director of the Parent/Professional Advocacy
League, which represents families with mentally ill children.

"If it lights up, you need to call your mechanic, find out what the
problem is and if it needs to be repaired," she said.

One of the league's family support specialists, Kathy Hamelin of
Fitchburg, said her own experience as the mother of an autistic son has
convinced her that expanded early screening is one of the best things to
come out of the Rosie D. case.

When her now 17-year-old son, Kevin, was a toddler, she said, he would
scream and cry all the time, smash his head against the wall when
frustrated, and flap his hands bizarrely. When she asked her
pediatrician about the hand-flapping, he said, "That's nothing. That's
just an excitement reflex and he'll outgrow it." In fact, she said, it
is a classic autism trait. Kevin's diagnosis and treatment came only
years later.

If the pediatrician had used an autism screening tool, it might have
sounded an early alarm.

"Our family suffered tremendously because of this," she said, "and I
just feel like if he had had early diagnosis, not only the pain and
frustration we felt as overwhelmed parents would have been less, but we
would have received early intervention," which "would have put him in a
much better position than he is now."

As the routine screening gets underway, the state will be tracking how
many children are tested and how many screens indicate a need for
follow-up, said Emily Sherwood, who is overseeing the state's remedy for
the Rosie D. case as director of its Children's Behavioral Health
Interagency Initiatives. The state also plans to expand mental health
services for children and make them more family friendly.

She said parents and clinicians may decide on a variety of responses to
worrisome scores: to wait and watch a while. To handle the problems
themselves. Or to seek a referral to a mental health specialist.

The screenings in doctors' offices "help us understand mental health as
a part of health," she said. "It's really up to parents and primary care
clinicians how they want to use this tool."
Medicaid law already requires that children be screened annually for
various problems, such as hearing and vision loss, as well as for mental
illness. This new requirement specifies the method of screening for
mental health problems, asking clinicians to choose from among eight
standard tools for the screening. Each screen is geared toward a target
age; some look for specific problems, such as substance abuse and
autism.

Research suggests that the screens will boost the number of children
referred to mental health providers - but not overwhelmingly.

Dr. Karen Hacker, executive director of the Institute for Community
Health at Cambridge Health Alliance, has used and researched mental
health screening for four years, and has found that between 5 percent
and 7 percent of children score high enough to cause concern. Other
practices have found rates as high as 12 percent.

But, she pointed out, many of those children were already in counseling.
Some families decided not to pursue further help, and of those who did,
many did not show up at appointments. She has not seen a dramatic uptick
in the use of psychiatric medications since the screens were added to
routine care, she said, though she understands that is a cause for
concern.

"We're going to have to see how this unfolds," she said.

Carey Goldberg can be reached at goldberg@globe.com.
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