Results identified a number of quality concerns regarding the psychiatric care received by children and youth in the child welfare system. These included overuse of medication, overmedication, and discontinuities in psychiatric treatment. The one psychiatric intervention that participants agreed was needed, inpatient treatment for psychiatric stabilization, was deemed of insufficient duration to help.
One central story that emerged from the findings was a complicated tale of the interrelated causes behind the perceived overuse and overmedication of some children in the child welfare system. Overuse, as reported by our participants, has four identified direct causes: external pressures by stakeholders to control youths’ behaviors, short psychiatric evaluations, a shortage of psychiatrists that will accept Medicaid and psychiatrists’ liability concerns. Overmedication shares most of these same direct causes, but also may be due to short inpatient stays and limited communication across disciplines about target symptoms, the context of a child’s behavior problems, and medication side effects. External pressures to control youth behavior within the context of either short evaluations or short inpatient stays can create potent scenarios for both overmedication and overuse of medications.
Short psychiatric evaluations and consultations are driven primarily by pressures on psychiatrists from their employers to maximize the income produced. The Medicaid payment structure plays a substantial role in this pressure. In such an environment, services to patients that are reimbursed from Medicaid will likely be brief. Psychiatrists may be unwilling to conduct longer evaluations at Medicaid rates when other patients that pay better could be seen. Other psychiatrists may choose not to serve Medicaid patients at all, contributing to the dearth of psychiatrists willing to serve child welfare clients. Medicaid policies are also behind short inpatient stays. Hospitals will naturally be reluctant to keep patients for periods longer than Medicaid will reimburse.
The reluctance of child welfare and residential employees to provide relevant clinical feedback to prescribing psychiatrists has three identified root causes: a desire to not offend psychiatrists willing to work with their clients, child welfare professionals’ lack of knowledge about psychiatric issues and psychotropic medications leaving them often unwilling to voice their opinions, and their concerns about liability if they choose not to follow the psychiatrists’ prescribed medication plan. In short, some child welfare professional do not feel empowered to share their views. In addition, there is no venue, such as a team-planning meeting, where psychiatrists and other professionals come together, in which to share information.
Children in the child welfare system usually do not have an involved parent driving psychiatric care. An involved parent may disagree with a psychiatrist’s diagnosis of a child she knows well. Or, an involved parent may provide feedback to a psychiatrist when a child exhibits side effects such as drowsiness, allowing a change in dosing or medication. The stakeholders in the child welfare system (residential care employees, child welfare case managers, foster parents) may not be adequately filling this role usually fulfilled by the parent seeking services.
We chose not to fully explore with our participants the causes behind discontinuities in psychiatric treatment. This concern arose fairly late in our field work and we felt the causes were fairly circumscribed, limited to employment and contractual practices. Residential programs and some private contractor agencies (like those providing treatment foster care) have service contracts with individual psychiatrists. Inpatient programs are also often affiliated with certain psychiatrists. When a child enters these programs, they are assigned to the psychiatrists affiliated with these programs no matter what psychiatrist was seeing them previously. When children leave these specific programs to live in the community, they are served by whatever psychiatrist the case manager can find that will accept Medicaid. In short, psychiatrists don’t follow children from placement to placement.
The second story to emerge from these data is a deep underlying skepticism toward psychiatrists by many of the professionals we interviewed, especially the child welfare workers. Their tone in interviews was often derogatory and dismissive of psychiatrists’ professional opinions. While in the presence of psychiatrists, child welfare professionals may be quiet and reluctant to voice their opinions; among their own, however, psychiatrists received little respect. Recently, American Psychiatric Association President Steven Sharfstein referred to a crisis of credibility for American psychiatry among the general public, based largely on problems with quality and access (Sharfstein, 2005
). This research suggests that the crisis of credibility extends beyond the general public to professionals that deal regularly with psychiatrists.
This crisis of credibility may result, at least partially, from psychiatrists struggling to practice within the structural constraints of modern marketplace medicine. While the government attempts to keep Medicaid growth in check with low reimbursement rates and managed limits on services, psychiatrists are expected to maximize income for either their private practices or the community agencies that employ them. Meanwhile, psychiatric consumers want thoughtfully delivered care. Additional stakeholders desire quick help for acute problems. This creates an intra-role conflict for psychiatrists who cannot maximize income in such a reimbursement system and
provide quick fix solutions that satisfy demanding stakeholders and
provide high quality care. Ethnographic observers have described the mandate for industrial efficiency in modern psychiatric practice (Donald, 2001
; Luhrmann, 2000
), and how modern mental health professionals are judged not by the quality of their clinical work, but by the quantity of the hours billed (Robins, 2001
American Academy of Child and Adolescent Psychiatry guidelines (2003)
call for thorough psychiatric evaluations for children that require several hours to complete. Knowing this and feeling forced to evaluate children in much shorter time periods likely causes some psychiatrists professional distress that is hard to reconcile. Psychiatrists in this practice context may risk suffering from what Ware, Lachicotte, Kirschner, Cortes, and Good (2000)
called a loss of moral vision of good mental health treatment. In order to reduce the tension caused by the feeling that they may be forced to provide what they consider inadequate care, psychiatrists may re-define in their own minds what adequate care looks like.
This study identified additional opportunities for research. These include research that (a) provides rich description of the professional lives of practicing psychiatrists, to explore how they manage the conflicts between a desire to provide high quality care and the external constraints placed on them, (b) explores administrators and psychiatrists viewpoints of needed structural changes to enhance practice processes and outcomes (c) examines psychotropic medication use in relation to clinical need for child welfare and other child consumers, (d) explores how to better implement guideline concordant prescribing practices, (e) quantifies the amount of time psychiatrists spend with young patients and explores the relationship between time spent and patient outcome, and (f) examines the impacts of inpatient stays of differing durations.
The study was designed to examine issues of psychiatric treatment in two counties of one state. Although child welfare and mental health systems have similarities across jurisdictions, unknown variations in psychiatric and child welfare practices, Medicaid and child welfare policies, and court systems make it unknown how tied the findings are to geographic location. In addition, different researchers may have pursued different paths of inquiry as the project unfolded.
We used two different interview types: group and individual. It is possible that this decision affected results in unknown ways. Child welfare professionals’ comments about psychiatric care might not have been as pointedly negative without the group context. And psychiatrists, who were generally polite in their descriptions of child welfare practices and professionals in individual interviews, may have been more derogatory in their comments in a group context. Although we sought a variety of viewpoints, it is possible that child welfare professionals with negative views of the child welfare system, the child mental health sector or both were more motivated to participate in the study.
Clinical, Administrative and Policy Implications
The results, coupled with the results from Hurlburt et al. (2004)
point to a need for increased capacity for the coordination of psychiatric care for child welfare consumers, particularly for mechanisms to support a team approach that increases communication across disciplines. The reimbursement system, again, serves as a key impediment, as it typically does not reimburse mental health professionals for time spent attending case planning meetings or phone consultations with referring professionals. No matter the barriers, child welfare professionals and psychiatrists need to find mechanisms to communicate. When they do, child-serving psychiatrists may need to alter their partnering strategies with child welfare professionals to address the reticence of these collaborators to voice their concerns and to ensure that psychiatrists receive the clinical feedback that serves as a corrective force in treatment. Some professionals may need more education and assurances about the medications being prescribed than other professionals. The study also identifies a need for training for child welfare professionals to help them partner better with psychiatrists. This could include background information on psychiatric disorders, psychotropic medications, and the kinds of information psychiatrists need from their clinical partners. We believe that with proper coaching, child welfare professionals are capable of being effective treatment partners in psychiatric care.
Administrators in mental health agencies and psychiatrists need to begin dialogue that addresses the causes and repercussions of services delivered in 15 min increments. With the ongoing shortage of child-serving psychiatrists, agencies that can provide a practice environment conducive to quality service will have a recruitment and retention advantage.
The interplay between well-known system structure issues often voiced by psychiatrists and consumer advocates and complaints about the quality of current psychiatric practice for a vulnerable population voiced by non-psychiatrists was striking in these findings. A national shortage of child-serving psychiatrists, malpractice concerns, Medicaid reimbursement rates that psychiatrists and mental health agencies view as too low, and a productivity based incentive system that has led to 15 minute appointments all serve as enormous barriers to improved psychiatric care. Each of these barriers has its own complicated socio-political history that has contributed to the entrenchment of these problems. The problems in quality attributable to these problems and how they affect psychiatric consumers have not yet been well described. A number of key players (psychiatrists, consumers, other mental health and social service professionals) are aware of these problems. Some of these groups, such as child welfare consumers, have little to no voice in the making of policy and no single group likely has sufficient pull to affect change in entrenched social policy. Together, these groups may have substantial clout to advocate for a reimbursement and system structure that promotes quality service.