The state was ranked 48th in providing children with mental health services in a recent report
Under a sweeping plan created by California’s health agency, the state has proposed solutions to longstanding challenges for low-income parents that include improved access to an array of pediatric mental health services — before children reach a crisis state.
Current state policy requires a diagnosis for clinicians in California to treat a child receiving Medi-Cal, the state’s version of Medicaid. For children with complex mental health conditions that require observation over time and a battery of tests — and absent clearly diagnosable symptoms — psychiatrists and therapists cannot bill for services.
According to mental health experts who are critics of the state’s restrictive policy, that often leaves children with profound histories of trauma waiting for services or interventions for far too long.
“The problem isn’t that we’re having trouble identifying kids who need the services,” said Dr. Rhea Boyd, a pediatrician at the Palo Alto Medical Foundation. “The problem is that kids haven’t been able to access the services that their teachers, their providers and their parents know they need.”
In June, California officials with the the Department of Health Care Services submitted an extensive proposal to the federal government to reform the state’s sprawling Medi-Cal system, which provides nearly 14 million children and adults with physical, mental and oral health care. The comprehensive restructuring and financing reform aims to provide an alternative to costly crisis care by offering a broader array of preventative care and services.
Under the portion of the plan that alters behavioral health care, many more children and adults will be able to access treatment without a diagnosis. That change is expected to enable California to better live up to a federal mandate that guarantees medically necessary care for all pediatric Medi-Cal recipients.
Dr. Kelley Gin, chief of clinical programs at the Oakland-based WestCoast Children’s Clinic, said part of the problem is that there is no simple, textbook diagnosis for children who have survived adverse experiences at an early age.
Referring to recent clinic clients, Gin said a lack of proper diagnoses has often caused them to miss out on treatment that could have helped them heal from traumatic childhoods. Gin described their behavioral issues as often stemming from the instability of early years — the incarceration of parents and transient living situations, like moving in and out of motels.
Gin said a pediatrician in the Bay Area recently sent one boy home with a prescription for the stimulant Ritalin after he ripped up an exam room in the first 10 minutes of his appointment, tossing toys and furniture. But medication, rather than the right services and counseling, made his situation worse, he said.
Years later, the boy’s caregiver brought him to the WestCoast Children’s Clinic, desperate for help. The drugs he had been prescribed only acted as “rocket fuel for his anxiety and his sense of distress,” Gin said. The boy’s violent outbursts had increased, and he was no longer able to remain in school.
Behavioral health issues are increasingly common for young people — particularly during the pandemic. The hospitalization of children seeking help for emergency mental health issues has shot up by 35% over the past year, according to California Health and Human Services Secretary Mark Ghaly.
Roughly 5.5 million young people in California rely on Medi-Cal — more than half of all children in the state — but the state’s public health care system has often struggled to provide them with timely behavioral health services. A 2020 report by the Commonwealth Fund found California ranks 48th among 50 states for providing children with mental health care.
In 2018, fewer than 5% of children on Medi-Cal received “specialty mental health services,” despite a federal entitlement guaranteeing access for all those eligible. Specialty services are used to treat everything from attention deficit and eating disorders to depression and schizophrenia.
The Early and Periodic Screening, Diagnostic, and Treatment program offers matching federal funds to states for services to “correct or ameliorate” a young person’s mental health condition. But California’s policy that requires a diagnosis before treatment has choked off treatment options for many children, according to interviews with health care experts and clinicians.
That situation has worsened during the pandemic, when large numbers of kids have experienced deep depression and anxiety. Earlier this month, California Gov. Gavin Newsom (D) announced unprecedented investments in mental health care, including $4.4 billion over the next five years for behavioral health services for young people through age 25.
Meanwhile, state officials, health and children’s rights advocates and medical and mental health providers have spent the past two years working to modernize and redesign California’s public health care delivery system. The changes include a “whole person care” approach and improving health outcomes to reduce racial health disparities and address social determinants of health, among other reforms. The series of complex finance and policy changes must be sent to the federal government in the form of a waiver to existing law.
On June 30, California submitted its plan to the U.S. Department of Health and Human Services and systemic changes are expected to launch early next year, once federal approval is granted.
The changes to behavioral health care involve a shift away from reliance on diagnoses, toward a system that responds to a child’s level of impairment due to traumatic life events — everything from abuse to poverty and societal racism.
Under the waiver plan, young people who have experienced foster care, the juvenile justice system or homelessness would automatically be eligible for intensive mental health services. Other children would face a different standard in order to qualify for that level of treatment. Rather than a diagnosis, they would receive services only after receiving a high score on an assessment tool screening for trauma.
While the state has not yet said which screening tool it plans to rely on, some experts in the field expressed concern that California will rely on an adverse childhood experiences (ACEs) screening tool that is already in use by Medi-Cal providers.
Although the tool has proven effective in studies for flagging toxic stress and the susceptibility to a host of chronic illnesses later in life, screening for adverse childhood experiences in doctor’s offices has been challenged by health and child welfare researchers in the U.S. and abroad. As detailed in a 2020 exposé by The Imprint, critics call use of ACEs in screening pediatric patients inappropriate and unethical, straining doctor-patient trust and drawing unfair scrutiny from child welfare investigators.
In public comments providing feedback on the state’s health care overhaul, patient advocates repeatedly expressed similar concerns about relying on a screen for trauma, and making a high score a condition for receiving intensive mental health care. Needy children who do not score high enough could be left unserved, they said.
Dr. Boyd, director of strategy and equity for the advocacy group California Children’s Trust, also has concerns she shared with the state. Boyd said trauma screening tools are not supported by research and could serve to simply replicate barriers in the state’s current system — a system which too-often denies mental health services to low-income Californians, particularly Black and Latino families.
Instead of depending on a trauma score, Boyd said the state should allow Medi-Cal providers to work with all youth who have emerging mental health conditions, or who have experienced trauma, despite the potential financial costs.
“At the same time that we’re trying to save costs and penny-pinch kids, that is only translating into chronic unmet behavioral health needs,” Boyd said in an interview. “Serving children and youth’s behavioral health needs enables them to thrive socially, emotionally, physically and mentally. Every child deserves that opportunity.”
When Gin first begins to work with severely traumatized children at the WestCoast Children’s Clinic, he said, they often can only manage 20 to 30 minutes of therapy before meltdowns happen — which include hurling objects at their therapist, or bolting out of the clinic and into the street, like one boy he remembered.
“He’d get unhinged when he had to be in a play room with this stranger who’s trying to be nice,” Gin said. “He was obviously frustrated and anxious.”
Over time, Gin said he aims to match children and their caregivers with resources that address their trauma. He pairs these children with psychiatrists who are able to taper them off psychotropics, and makes sure they have an individualized learning plan at school. Gin also helps them build stable relationships in the community, like helping some join a local Boys & Girls Club.
And things often turn around.
“We shouldn’t have to wait for things to get bad,” he said. “When we intervene earlier, it increases the odds that we’ll see a better outcome.”
Correction: This article has been revised to reflect Gin’s patients as composite characters, not as an individual patient.