Prevention and Early Identification of Mental Health and Substance Use Conditions News

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The Medicaid program provides coverage to 27 million children under age 18 in the United States. A core component of this coverage is the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, which ensures that the health care needs of children and youth are addressed to maximize their growth and development. Prevention and early identification of health conditions, which is a key component of EPSDT, promotes positive health outcomes and can reduce health care costs across an individual’s lifespan. The Center for Medicaid and CHIP Services (CMCS) is issuing this Informational Bulletin to help inform states about resources available to help them meet the needs of children under EPSDT, specifically with respect to mental health and substance use disorder services.

Many of these resources are from states themselves, and we look forward to continuing to work with states and stakeholders to add to this resource list and to provide further assistance in ensuring that children receive the care they need. Please contact John O’Brien at john.obrien3@cms.hhs.gov for questions about this Bulletin or to suggest additional resources.

Background

According to the U.S. Surgeon General, while 11 percent of youth have been diagnosed with a mental illness, two-thirds of youth who have a condition are not identified and do not receive mental health servicesi. Research by the National Institute on Mental Health found that half of all lifetime cases of mental illness or substance use begin by age 14ii. Recent information regarding mental health and substance use disorder conditions among children indicates:

• The rate of current illicit drug use among all youth (Medicaid and non-Medicaid) aged 12 to 17 is 10.1 percent, 25% higher than individuals age 18 or older.
• Suicide was one of the top 10 causes of death of students in the United States in 2009iv. Almost 14 percent of these students have seriously considered suicidev. Six percent report having attempted suicide one or more times in the past 12 months. The presence of major depression, bipolar disorder and alcohol and drug abuse are frequent risk factors for suicidal behaviors.
   
• Children exposed to trauma, including maltreatment, family violence, and neglect, exhibit symptoms consistent with individuals diagnosed with post-traumatic stress disorder, attention deficit/hyper-activity disorder, depression, and conduct disorder/oppositional defiant disordervi.

Mental Health and Substance Use Disorder Screening in EPSDT

The EPSDT benefit is Medicaid’s comprehensive preventive child health service designed to assure the availability and accessibility of health care services and to assist eligible individuals and their families to effectively use their health care resources. (See, 42 U.S.C. § 1396(r)(1)(B); and 42 CFR 441, Subpart B.) The EPSDT program assures that health problems, including mental health and substance use issues, are diagnosed and treated early before they become more complex and their treatment more costly. Under the EPSDT benefit, eligible individuals must be provided periodic screening (well child exams) as defined by statute. One required element of this screening is a comprehensive health and developmental history including assessment of physical and mental health development. Part of this assessment is an age appropriate mental health and substance use health screening. As noted in the section above, early detection of mental health and substance use issues is important in the overall health of a child  and may reduce or eliminate the effects of a condition if diagnosed and treated early. If, during a routine periodic screening, a provider determines that there may be a need for further assessment, an individual should be furnished additional diagnostic and/or treatment service.

In addition to the required periodic screens, EPSDT provisions ensure that children receive medically necessary physician screenings in order to detect a suspected illness or condition not present or discovered during the periodic exam. The screening may also trigger the need for a further assessment to diagnose or treat a mental health or substance use condition.

Clinical Guidelines and Screening

Significant advancements in early detection of mental health and substance use conditions have taken place over the past decade. Numerous validated screens are available for use by medical professionals, and extensive research has proven them effective. Further, professional resources are growing to assist primary care providers in the identification and treatment of conditions, and when necessary, linkages to specialists are improving. This includes tools that can assess the social and emotional development for infants and young children.

Numerous organizations in the medical community have issued clinical guidelines calling for early identification and screening for mental illness and substance use disorders. For instance:

• The American Academy of Pediatrics (AAP), through its publication Bright Futures, recommends an assessment of psychosocial and mental health and substance use at all well-child visits, newborn to age 21. In 2009 the AAP released an extensive toolkit for its members to assist them in the identification and treatment of these conditions among their patients. http://brightfutures.aap.org. In addition, AAP has released guidance regarding Screening, Brief Intervention and Referral to Treatment ( SBIRT), improving mental health services in primary care settings and recognizing and managing perinatal and postpartum depression. These briefs can be found at: http://pediatrics.aappublications.org/content/128/5/e1330.full.html
  http://pediatrics.aappublications.org/content/123/4/1248.full
  http://pediatrics.aappublications.org/content/126/5/1032.full.html
   
• The Society for Adolescent Medicine released a position paper “Meeting the Health Care Needs of Adolescents in Managed Care,” which focused on mental health and substance use conditions. http://www.adolescenthealth.org/AM/Template.cfm?Section=Position_Papers&Template=/CM/ContentDisplay.cfm&ContentID=1481
   
• The American Medical Association (AMA) released its Guidelines for Adolescent Preventive Services (GAPS), which includes recommendations for mental health and substance use screening. http://www.ama-assn.org/resources/doc/ad-hlth/suicidealgor.pdf
   
• The Surgeon General released the 2012 National Strategy for Suicide Prevention that provided specific recommendations for developing and implementing protocols and programs for clinicians and clinical supervisors, first responders, crisis staff, and others on how to implement effective strategies for communicating and collaboratively managing suicide risk. http://www.surgeongeneral.gov/library/reports/national-strategy-suicide-prevention/full_report-rev.pdf
   
• The American Society of Addiction Medicine (ASAM) developed training for healthcare professionals to appropriately screen for and identify substance abuse, plan and implement a tailored brief intervention, improve care management and referral skills for brief treatment or severe problem/addiction treatment. http://www.sbirttraining.com
   
• National Institute Alcohol Abuse and Alcoholism’s (NIAAA) empirically based “Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide” was designed to allow practitioners who manage the health and well-being of children and adolescents to conduct fast, effective alcohol screens and brief interventions. The guide was released in October 2011. The American Academy of Pediatrics (AAP) endorsed the guide. The guide was also focus tested with pediatricians as well as family practice physicians, nurse practitioners and physician assistants. http://www.niaaa.nih.gov/publications/clinical-guides-and-manuals/alcohol-screening-and-brief-intervention-youth
   
• The United States Preventive Services Task Force (USPSTF) has also developed recommendations for primary care clinicians and health systems. In March 2009, the USPSTF reviewed and issued recommendations regarding screening for various mental health and substance use among people age 12 years and older. The USPSTF preventive services recommendations for these screenings can be found at http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.

There are a number of screening tools that are recommended by these various medical associations for use to identify children and adolescents with a mental health and/or substance use condition. Several tools also assess the social and emotional development of infants and young children.

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