How Nevada struggles to help children battling mental illness

It is the source of anxieties and sadness no mother would wish on herself. Inside, bulging paperwork tells the story, in the brutal coldness of clinical reports, of her son’s battle to be happy.

“I would hope there is no parent who has to collect this amount of data on their child,” she says, sitting in her spacious Summerlin home.

On the cover is a photo of her 15-year-old son, Leo, whom she and her then-husband adopted as a newborn. (Her son's name has been changed per McKenna's request.) They instantly fell in love with their sweet, snuggly baby and didn’t think much of his occasional temper. What baby doesn’t throw food across the room once in awhile?

When his prolonged crying and yelling increased over time, the couple enrolled Leo, then 4, in sessions with a child therapist. Eleven years later, Leo has seen more than 30 medical professionals and received a mishmash of diagnoses: oppositional defiant disorder, depression, bipolar, conduct disorder, attention deficit hyperactivity disorder and autism spectrum disorder. The diagnoses change so often that McKenna usually just says “mental health issues.” No matter what the doctors come up with, she worries her son isn’t receiving the help he needs.

“How do you treat something that you don’t know what it is?”

More importantly, she shies away from the diagnostic terminology because she doesn’t want her son — lanky, witty and with a penchant for video games — stigmatized by a label. That’s why a photocopied portrait of Leo graces the cover of the binder, which is jam-packed with hospital discharge summaries, medication information, therapy notes and individualized education plans. Her son is a person, not a diagnosis.

Her binder, which she started eight years ago after Leo’s first neuropsychological evaluation, is an attempt to keep order amid the chaos in Southern Nevada’s fragmented mental-health system.

The binder is a necessary evil. Nevada is one of the worst states in helping children whose turbulent emotions and behaviors shape their lives.

• • •

Two years ago, the Centers for Disease Control and Prevention released a report -- the first of its kind -- estimating the prevalence of mental disorders among children. The study found that 13 to 20 percent of children, ages 3 to 17, in the United States experience a mental disorder in any given year.

Nevada seems to fall within the higher end of that range. By some estimates, 1 in 5 elementary-school children grappled with behavioral health problems, and a third of the state’s adolescents said they were anxious or depressed. Even more troubling: About a quarter of Nevada’s middle-school students have seriously considered suicide. Among those, half have tried to kill themselves.

Nevada is serving a greater number of mentally ill children in recent years. Five years ago, 21,887 children in Nevada received mental health services from the state. In the last fiscal year, 33,550 children received care, according to data from the state’s Medicaid program. Because that data includes Medicaid recipients only — and not those covered by private insurance — the actual number of children receiving mental health services is even greater. And then there are children in need who receive no services.

State officials say the uptick may be attributed to more children covered by insurance because of the state’s Medicaid expansion and the Affordable Care Act. Also, more problems may be identified because of greater mental health awareness.

Simply put, many of our children aren’t well. These children may have no nasty coughs, broken bones or sore throats, but they’re struggling with forces affecting how they think, feel and act. This is what experts refer to as mental health, the term that describes a person’s emotional, psychological and social well-being. It can range from clinical depression caused by problems like poverty or abuse at home to serious biochemical problems.

“This is an epidemic,” said Dr. Jay Fisher, who directs the pediatric emergency department at University Medical Center, where he sees children in crisis each day. Decades ago, he said, physicians looked to vaccines to preventing epidemics. “This is going to be much more difficult to solve. It’s a 12-headed beast.”

Poor mental health takes a toll on a person’s life, no matter how serious the problem. But there’s a financial impact as well. The United States estimated that, in 2013, mental problems for people younger than 24 cost $247 billion, including health care, social services, juvenile justice and decreased productivity.

In the last fiscal year, Nevada spent $194.8 million treating children with mental health problems, according to Medicaid data. That cost has been rising for several years.

As for state spending on mental health services, Nevada fell in the bottom half of states during fiscal year 2013. Nevada’s per-capita spending on mental health services was $89.41, below the national average of $119.62, an analysis by the Henry J. Kaiser Family Foundation found. The amount placed Nevada No. 33 among states, the District of Columbia and Puerto Rico (New Mexico and Florida did not supply data for the analysis).

The cascade of problems it creates isn’t lost on state leaders. They’re hoping an $11 million federal grant recently awarded to Nevada will be the catalyst for change.

• • •

As the state and local entities look to expand mental health services for children, McKenna — a marketing consultant who shares custody of her two children with their fathers — has one question: How will families with private insurance fare?

A federal law passed in 2008 made some strides in mental health treatment. The law requires parity between mental and physical health insurance benefits — meaning deductibles and co-pays shouldn't be higher and days of coverage shouldn't be any more restrictive for mental disorders than they would be for other medical needs. But the problem, advocates and parents like McKenna say, is that treatment for mental health occurs over a longer period of time and, thus, becomes more costly.

Two years ago, her son’s problems worsened at the onset of puberty. Leo, then 13, ended up at Spring Mountain Treatment Center’s acute unit because of extreme unhappiness and frequent angry outbursts.

The center recommended McKenna and her ex-husband place Leo in a long-term residential treatment center, where he could receive more intensive therapies to help control his emotions. With few in-state options, they chose Eagle Ranch Academy in St. George, Utah. The cost: $10,000 per month. Leo spent seven months there, but the family’s insurer at the time, Cigna, only covered the first few months. They paid out of pocket for the rest. She asks, “How many parents can spend $100 a week for counseling?”

As McKenna’s frustrations brewed, she stumbled upon a “60 Minutes” interview with Virginia State Sen. Creigh Deeds, whose 24-year-old mentally ill son attacked him and later killed himself. Leo has never shown violent tendencies despite his hot temper, but Deeds’ raw, emotional story stuck with McKenna.

Desperate, she wrote Deeds a letter, asking if he knew of extra mental health services for her son in Nevada. McKenna knew Leo’s stay in the residential treatment center wouldn’t be a panacea. He needed support in place for his return home.

Several days later, her phone rang. It was a state health official offering to enroll Leo in a state program called Wraparound in Nevada normally geared to Medicaid recipients, which would pair the family with a caseworker who could help coordinate Leo’s services, a mentor to work with Leo one-on-one twice a week and a family preservation program through Olive Crest. All the services were free.

“They were an amazing support system to me,” says McKenna.

Roughly a year later, after Leo’s emotions and behavior improved substantially, the state closed the case. Leo still sees his mentor, receives therapy and visits a psychiatrist, but the family pays out of pocket for what its private insurer won’t cover.

McKenna calls the extra services a blessing but worries for other families who haven’t been as lucky. “If you have a good team, it just really helps,” she says.

• • •

What falls under the umbrella of “mental health”? The short answer is, a lot.

The Diagnostic and Statistical Manual of Mental Disorders, a large purple book used by medical providers to classify disorders, includes page after page of mental health conditions, such as acute stress disorder, oppositional defiant disorder, schizophrenia, autism spectrum disorder, anorexia nervosa, major depressive disorder and addiction. The list ranges from anxiety to psychosis.

Adding to the complexity, disorders can be caused by genetics or brain chemistry, set off by environmental triggers such as trauma, or a combination of both.

Identifying the source of a disorder can be difficult, if not impossible. The bottom line: These children need help.

Nevada — and Clark County in particular — doesn’t provide enough. A large reason: Nevada’s chronic physician shortage, all the more painful because of the region’s population boom, difficulty recruiting doctors here and its lack of medical school and fellowship opportunities. Southern Nevada needs more primary care doctors, pediatricians, obstetricians and gynecologists and psychiatrists, among others.

The region’s dearth of providers means families face long waitlists, short medical appointments and few alternatives.

In September, Mental Health America, a nonprofit and advocacy organization, released its annual ranking of the state’s and the District of Columbia’s effectiveness in addressing mental health in all age groups. For the second year in a row, Nevada ranked 49th. Only Mississippi and Arizona scored lower. Nevada fared marginally better at serving youth — moving up to a 45th ranking after being at the very bottom last year.

The organization used the most recent national data to determine its rankings. It looked at the percentages of adults with mental illness. It compared numbers of youths who have experienced major depressive episodes. It examined statistics on adults and youth who didn’t receive mental health services, as well as children with private insurance that didn’t cover mental or emotional problems.

Low rankings in the report indicate a higher prevalence of mental illness and lower rates of access to care, the latter being the problem here.

“We’re not necessarily the highest in mental health problems with comparative states, but the problem is we have the lowest access to care,” said Ramona Denby-Brinson, a professor in UNLV’s School of Social Work who studies children’s mental health.

Nevada lagged behind Colorado, Arizona and Florida in delivering mental health services to children ages 2 to 17, according to a 2011-2012 health survey conducted by the Centers for Disease Control and Prevention. Colorado, Arizona and Florida are considered Nevada’s peer states because of similarities among Las Vegas, Denver, Phoenix and Orlando.

In Nevada, half of the children who needed mental services like psychotherapy or counseling did not receive them compared with 35 percent of children in Colorado, 40 percent in Arizona and 42 percent in Florida, according to the survey data. Nationwide, 39 percent of children did not receive the mental health services they needed.

The nationwide shortage of psychiatrists who treat children is especially severe in Clark County. The American Board of Psychiatry and Neurology lists 14 board-certified child and adolescent psychiatrists practicing in Las Vegas. Compare that to cities with similar population sizes: Portland, Ore., has 48. Albuquerque, N.M., has 37. and Milwaukee has 27.

Many psychiatrists who work here don’t accept private insurance because of low reimbursement rates and too much paperwork required by the insurance companies -- both of which limit the amount of time a psychiatrist can then spend with patients, said Dr. Lisa Durette, medical director of Healthy Minds, a local mental health agency.

It’s not just psychiatrists. Southern Nevada is also short on psychologists, social workers, counselors, marriage and family therapists and substance abuse specialists, advocates say.

The shortage burdens local clinicians, like Dr. LaTricia Coffey, who specializes in child and adolescent psychiatry. Before she can describe a typical work day, Coffey first must explain all the places she works.

She sees children, adolescents and adults in her private practice. She serves as medical director for the local Boys Town, a nonprofit that provides services for troubled children and their families. She contracts with Healthy Minds, a mental health agency that works largely with children in foster care. She provides psychiatric expertise for the Cleveland Clinic Lou Ruvo Center for Brain Health. And she works with mentally ill adults who have been court-ordered to receive outpatient treatment.

Coffey’s hectic schedule is partly by choice — she likes serving different populations — and partly because she couldn’t afford to pay her bills solely from her private practice.

“Because of (the shortage), there are so many opportunities to help children’s mental health,” she said. “We could choose to work anywhere we wanted and at any time.”

While good for business, being in demand gnaws at Coffey’s conscience because sometimes “you just have to tell people no — and it hurts.”

There are efforts underway to change that, including Clark County’s first fellowship program focusing on child and adolescent psychiatry, which began last year and is affiliated with the University of Nevada School of Medicine. Durette runs the program. Meanwhile, UNLV has embarked on a campaign to train more health professionals for children.

But catching up will take time.

• • •

Two years ago, a state-commissioned report analyzed Nevada’s public mental health services. A key finding: Nevada invests very little in prevention and early intervention for children and teens. Instead, the state has focused on adults in the throes of a crisis.

The situation irks people like Charlene Frost, the statewide director for Nevada PEP, a nonprofit that links families with resources for children. It seems like a no-brainer to her. If we don’t address our children’s mental health needs, the problem will only become larger over time, seeping into adulthood.

“We have to find some way to address this because none of us wants to see our kids end up in the largest psychiatric unit, which is the prison system,” she said.

One major hurdle: Nevada’s fragmented system of delivering services to children. It further stymies access to care — leaving families and caregivers bewildered about where to turn for help.

It’s a problem the Clark County Children’s Mental Health Consortium, one of three groups the state created in 2001 to address pediatric mental health issues, has been trying to fix for some time. (The other two consortiums are for Washoe County and the rural regions.)

“I think we are heading in the right direction, but the progress has been slow,” said Karen Taycher, a member of the Clark County consortium and executive director of Nevada PEP. “I think everybody agrees on the problems. The trick now is coming together on the solutions.”

That’s where the $11 million grant from the Substance Abuse and Mental Health Services Administration, a federal agency, comes into play.

The state officials who applied for the grant agree with McKenna and other advocates. “The continuum of care is currently a fragmented system that poses significant coordination and access of care issues,’” the grant application states.

The state hopes to use the money to create a “System of Care” that will shift treatment to the local level, while the state takes on an oversight role. Nevada is one of only three states where the state is the direct provider of many services.

“The state has always been a provider of services to kids with the most serious issues,” said Kelly Wooldridge, deputy administrator for the Nevada Division of Child and Family Services, who oversees children’s mental and behavioral health. “However, we estimate we only catch about 20 percent of those kids. Where else those kids are receiving services really hasn’t been apparent because everyone is siloed.”

As state officials work toward untangling snags, others are doing the same.

Several times a year, a group of doctors, mental health providers, school psychologists, juvenile justice workers and a judge gather in a Sunrise Hospital meeting room for an informal discussion about problems and fixes — all in the name of pairing children with the help they need more quickly.

Child and adolescent psychiatrists, meanwhile, are revamping the regional chapter of the American Academy of Child and Adolescent Psychiatry, which had been dormant for a handful of years. The new group’s first meeting was in July, and members hope to plug themselves into the broader conversation about children’s mental health.

“We are struggling to get people to acknowledge us,” Coffey said. “Traditionally child psychiatrists haven’t been part of the conversation. We felt unwelcome and they thought we were uninterested.”

Advocates say breaking down these barriers in the community will move toward ensuring that parents and caregivers, like McKenna, encounter no closed doors when seeking help for a child. “This is a community problem,” said Rosemary Virtuoso, a retired school psychologist in Las Vegas. “Not one piece of the mosaic is the solution or the cause.”

• • •

In August, Leo turned 15. He’s a ninth-grader at a Clark County high school, where he’s part of a self-contained classroom with eight other students.

It’s going well so far, and McKenna is hoping that maybe — just maybe — Leo is outgrowing some of his behavioral issues. This past summer, he attended a local engineering camp for teens and had no problems, a sign that he’s better controlling his anger.

But there’s still more recordkeeping to be done. McKenna needs to slide his latest individualized education plan into the trusty binder. She knows they’re not out of the woods yet, but she cherishes the moments of normalcy amid the outbursts.

Raising Leo, she says, has taught her so much about parenting. Her hopes and dreams for him have become simpler. She no longer cares if he plays sports, attends college or pursues a lucrative career. She wants him to have healthy relationships and be kind, happy, alive — virtues that she says are “are just so underrated but so important.”

McKenna knows pending changes in how Nevada cares for its mentally ill children might be too late for her son, but she will be paying close attention and speaking out when necessary. She doesn’t want other families — and more importantly, children — to fall through the cracks.

“I didn’t go through all of this for nothing,” she says. “There (must) be something I gained that I can share with others.”

[This story was originally published by the Las Vegas Sun.]

Photo by Mikayla Whitmore/Las Vegas Sun