Editor's Note: The Las Vegas Sun spent several months exploring community challenges created by lack of treatment for children with mental problems. The project was supported by the Center for Health Journalism at the University of Southern California's Annenberg School for Communication and Journalism. Today, we end our series with a look at solutions.
One by one, they entered a UNLV auditorium, escaping the chilly December air. They had come to discuss the mental health of Southern Nevada’s children.
Parents. Teachers. Psychologists. Psychiatrists. Pediatricians. Therapists. Social workers. Students. State leaders. Nonprofit executives.
A grandparent. A principal. A nurse. A victim advocate. A health district analyst. An associate professor. A medical society president.
About 200 people attended the community forum this month — some hoping for answers, some eager to share ideas and frustrations. Many grabbed brochures from resource tables as they walked in; others greeted caregivers who once worked with their children.
Whatever their backgrounds, they were all advocates on this night.
Ramona Denby-Brinson, a professor in UNLV’s School of Social Work who studies children’s mental health, welcomed them all. “This is a really critical time in our state with respect to mental health services, and we need to hear from you.”
The Las Vegas Sun partnered with UNLV’s Lincy Institute, the Clark County Children’s Mental Health Consortium and Nevada PEP, a parent advocacy organization, to host the forum. They urged attendees to ponder this question: As a community, how can we do better?
This year, the state received an $11 million federal grant to revamp how mental health services are delivered to children. Nevada is one of only three states that directly provides services. Under the forthcoming “System of Care,” the state would assess children but otherwise oversee services provided by community-based organizations or individual counselors, therapists, psychologists and psychiatrists, among others.
State leaders hope the new setup not only improves quality, but also connects children more quickly with the mental health services they need.
It’s a necessary intervention. Nevada ranks 45th in serving youth with mental health problems, according to Mental Health America, a nonprofit advocacy organization.
Six panelists — a child and adolescent psychiatrist, a pediatric emergency room doctor, a licensed marriage and family therapist and three parents who have children with mental health issues — kicked off the wide-ranging discussion that eventually included audience members.
Part of the struggle, they said, isn’t something that legislation or extra funding can change: the stigma of mental illness. Children hesitate to admit their inner turmoil. Parents fear reaction from friends, family and neighbors. Or they experience “blame-shaming” when they do share their children’s struggles.
“It is very hard for parents to reach out for help,” said Karen Taycher, executive director of Nevada PEP. “If I needed help with my child’s broken leg, that would not be hard at all … I blame the stigma.”
One way to reduce it: Keep talking about mental health. And so they did — for nearly two hours.
Along the way, a consensus emerged about what needs to happen to better care for children who have mental health problems. The following recommendations are based on the community forum discussion and additional reporting:
• • •
The state needs more mental health professionals.
Nevada lacks physicians of all sorts. When it comes to children’s mental health, Southern Nevada falls short on not only child psychiatrists but also social workers, counselors and therapists.
“We need clinicians who understand trauma, who understand diagnoses, who understand how to work with medications and psychiatry, when to hospitalize a kid (and) when not to,” said Jacqueline Harris, a licensed marriage and family therapist who chairs the statewide Children’s Mental Health Consortia.
Building such a workforce has been a challenge for a variety of reasons, including outsiders’ perspective of Las Vegas: It’s difficult to recruit talent when health professionals often seek an environment rich in academic opportunities. “It’s almost dishonest to tell people they’re going to really enjoy a professional, academic, intellectual environment,” said Dr. LaTricia Coffey, a child and adolescent psychiatrist.
With planned medical schools at UNLV and Roseman University hoping to start classes by fall 2017, that could change. Until then, Coffey said legislators should consider offering loan repayment programs to attract newly-minted child and adolescent psychiatrists.
Another snag had been licensing mental health professionals who did want to work in Nevada. Critics complained it was an arduous process, sometimes involving additional testing, that could take months to complete. The result: Professionals shied away from moving here.
This year, the Nevada Legislature tried to ease some of those challenges with bills to speed up the licensing process for physicians, nurses, psychologists, social workers and clinical professional counselors. Licensing boards must notify an applicant within 15 days if additional information is required. If the application is complete, the board must approve or deny the license within 45 days or 10 days after receiving fingerprint results — whichever takes longer. Another bill approved Nevada’s entry into the Interstate Medical Licensure Compact, which streamlines the licensing process for physicians who want to practice in multiple states.
“The legislation that was passed in 2015 was a positive step forward,” said Victoria Carreon in September. She is the director of education policy at the Guinn Center for Policy Priorities and has authored several reports about mental health.
Tim Burch, who directs Clark County’s Department of Social Services, said he would like to see state officials recruit more mental health workers.
“I would hope the state would use the same level of energy to bring (mental health workers) from other states into our area like we did recruiting Tesla and other economic engines,” he said in August. “If we have proper mental health services here, it helps fuel all our other sectors.”
• • •
The state needs to keep reforming its children’s mental health system.
When state officials applied for the $11 million federal grant, they acknowledged the system was “fragmented” and riddled with “significant coordination and access to care issues.”
In other words, families struggle to find mental health professionals who can see their children in a timely manner. When treatment does begin, service providers often don’t communicate well. Confusion mounts, leading to frustrated families and children who aren’t receiving proper care.
The four-year grant, which amounts to about $2.7 million annually, certainly won’t fix everything, and it’s too soon to tell exactly how the “System of Care” will look years down the line. But state officials have outlined a general vision:
• They want families involved in treatment that’s provided in the home or community. Residential treatment — long-term care provided at in-state or out-of-state centers — should be reserved for children with the most severe emotional and behavioral needs.
• They want services to be easily accessible to all Nevada families, whether they speak English or another language and whether they live in an urban or rural area.
• They want the state to monitor the effectiveness of mental health services, while community-based organizations, clinics and individual health professionals provide them.
“We right now don’t have a system of ensuring quality,” Taycher said. “Other states have developed quality standards for care of children’s mental health.”
To improve services, some states require accreditation for organizations providing mental health services, such as crisis stabilization, day treatment or psychosocial rehabilitation, said Lynda Gargan, executive director of the National Federation of Families for Children’s Mental Health.
States that require accreditation tend to weed out low-quality caregivers, she said. “It makes a good first cut.”
Another useful oversight mechanism: an advisory panel made up of families involved in the children’s mental health system. The advisory panels — some of which include teenagers receiving mental health services — alert state officials about what’s working, what’s not and what more needs to be done.
“Just like anything else, it’s important to have (the perspective of) people using any service,” Gargan said last week.
The state has been examining best practices elsewhere that could be included in Nevada’s new system, said Kelly Wooldridge, deputy administrator for the Nevada Division of Child and Family Services, who oversees children’s mental health.
“I’m hoping four years from now, I can come back and say we got there,” she said.
• • •
Parents need to stay engaged with their children.
Consider how common these problems are: The Centers for Disease Control and Prevention estimates that as many as 20 percent of minors in the United States experience a mental disorder in any given year.
Parents should be ready, said Dr. Jay Fisher, who directs the pediatric emergency department at the Children’s Hospital of Nevada at University Medical Center. “The world is moving very fast, and there’s nowhere for these kids to hide,” he advised the audience. “They’re going to have that day where it’s the worst day. What are you going to do?”
Coffey, a child and adolescent psychiatrist, gave simple advice: Talk to your kids and find out how they are feeling.
“Ask them in a nice way,” she said. “Ask them in a joking way. Be nosy. Be annoying.”
And when your child does encounter mental health problems, employ the same tactic with health providers — doctors, psychiatrists, therapists, educators. It takes a team to support a struggling child or teen, so everyone involved in his or her life should be communicating with each other.
Navigating the system won’t be easy.
The state chapter of the National Alliance on Mental Illness hopes to introduce in Southern Nevada early next year a program called NAMI Basics. Geared toward parents, the free, six-week course arms caregivers with information about mental disorders and provides self-advocacy skills for dealing with schools, behavioral health agencies and the juvenile justice system.
In essence, the program teaches parents and caregivers to be the “CEO of your child’s care,” said Linda Porzig, education program administrator for NAMI Nevada.
“We teach the parents not to feel guilty,” she said. “We know that early intervention is everything.”
• • •
Children need to be screened for mental health problems.
As state officials revamp the service-delivery system, they’re considering whether to implement a screening program that would identify middle school-age children at risk of mental health problems.
The proposal represents a shift from focusing on crisis treatment to early prevention and intervention. If the screening indicated a child were at risk for mental health issues, he or she would be referred to services through Medicaid, private insurance or the state Division of Public and Behavioral Health.
“We want to take away the stigma of mental health, suicide and addiction and say, ‘You know what? It’s so pervasive that every seventh-grader should be screened,” said Richard Whitley, director of the Nevada Department of Health and Human Services, in September.
Now, it’s a matter of whether insurance will cover those screenings. As a first step, the state submitted its plan to the Centers for Medicare and Medicaid Services. An approval would pave the way for Medicaid reimbursement.
“The challenge will be, will the public and, ultimately, legislators support (the screening)?” he said. “We want to at least have the discussion.”
At the community forum, Jacqueline Harris, a licensed marriage and family therapist, urged the state to add more mental health workers to accommodate an expected influx of children. “I don’t want to see a situation where we are identifying (children) and then we say, ‘Your child has an issue. Good luck.”
• • •
Stakeholders need to develop a blueprint for funding.
What will much of this take? Money.
Last year, Gov. Brian Sandoval directed nearly $2 million to expand the state’s Mobile Crisis Response Team. During the legislative session, lawmakers approved a $16 million grant program to place more social workers and other licensed mental health professionals in schools over time. (Sandoval originally requested $36 million.)
Meanwhile, the Legislature awarded $27.5 million this fiscal year for Southern Nevada Child and Adolescent Services, which provides mental health services, and $27.6 million for the next fiscal year. Northern Nevada Child and Adolescent Services received $9.1 million and $9.4 million, respectively, for fiscal years 2016 and 2017.
“We made huge strides that need to continue,” Wooldridge said last week. “The only way we really turn the dial is also to put money, time and effort into early prevention and intervention.”
The state also may apply for two federal grants, one of which would go toward developing the workforce needed to address children’s mental health.
For many of these initiatives to move forward — and be sustained in years to come — stakeholders need to determine which areas need more funding and lobby for that money when the Nevada Legislature reconvenes in 14 months.
Nevada Assemblyman James Ohrenschall, D-Las Vegas, said he is optimistic. He knows the problem firsthand; as a Clark County public defender for the juvenile division, he represents many children with mental health issues.
“I don’t know what the silver bullet is other than we keep trying,” he said last week.
• • •
As the forum drew to a close, a mother waved her arm in the air. She had been waiting to share her story.
The audience already had heard from the panel. It also had heard from a father who felt shut down as he tried to help his self-harming daughter, the mother of adopted children with fetal alcohol syndrome who pleaded for more help and the founder of the Nevada Children’s Center who lamented the lack of in-state residential treatment options.
When the woman finally received the microphone, she talked about how she had knocked on every door — only to have many shut in her face — to find services for her daughter, who is now an adult. She didn’t give up. She urged others in the auditorium not to either.
Her road was difficult, but not without its own irony.
After all, she said, “I’m taking medication because my daughter refuses to take it.”