- Email: [email protected]
Mental Illness is Also A Disability—Even for Children
FEATURE ARTICLE
H. Barry Waldman
Dolores L. Cannella
H. Barry Waldman, DDS, MPH, PhD Dr. H. Barry Waldman is a Distinguished Teaching Professor of the State University of New York. He was the first faculty member of the School of Dental Medicine at Stony Brook where he has served for almost 40 years in numerous roles, including Department Chair and Assistant Dean. He has published 900 monograph and articles in international, national and regional publications evaluating health delivery and social issues, including manpower, health economics, delivery modalities, and quality assessment; with particular emphasis in the issues facing the delivery of health services to youngsters and older patients with special health care needs. Together with Dr. Perlman, he initiated the changes in the accreditation process that now requires all schools of dentistry and dental hygiene to provide training for students in the care of patients with special needs. Dolores L. Cannella, PhD Dolores Cannella is an Assistant Professor and Director of Behavioral Sciences at Stony Brook University, School of Dental Medicine. She lectures on a variety of topics relevant to the doctor–patient relationship, such as health literacy, cultural competency, dental anxiety, and health behavior change. Her research interests involve employing social psychological theories to investigate oral health promotion and disparities in oral health care services. She is the Coinvestigator of Stony Brook’s Pregnancy Project, whose current aim is to increase access to oral health care services for disadvantaged and underserved pregnant women.
Mental Illness is Also A Disability—Even for Children H. Barry Waldman, DDS, MPH, PhD, Dolores L. Cannella, PhD, and Steven P. Perlman, DDS, MScD
T
he enactment of the 2008 Mental Health Parity and Addiction Equity Act was a major step in an effort to eliminate health insurance benefit inequity between mental health/substance use disorders and medical/ surgical benefits. But individuals and their families may not seek needed care because mental illness could still remain an unrecognized disability, especially among children. The extent of the problem, related symptoms, some approaches for care, and the involvement of dental practitioners are considered below. ‘‘The Americans with Disabilities Act (ADA) has a three-part definition of disability. Under ADA, an individual with a disability is a person who: (a) has a physical or mental impairment that substantially limits one or more major life activities; or (b) has a record of such impairment; or (c) is regarded as having such an impairment.’’1 ‘‘Have you ever seen someone park a car in a spot for individuals with disabilities, hang a parking pass on the mirror and then walk away? Did you ever then think to yourself, ‘They don’t look disabled’? Actually, what do individuals with a disability look like?’’2
Most people are able to recognize individuals with ‘‘obvious’’ physical disabilities. To a far greater extent than in the past, we recognize ‘‘viewable disabilities’’ and make needed accommodations—in school and work settings, an increase of ramps for architectural barriers, street curb cuts, enunciators in elevators, and beyond. But what of those disabilities that are not observable, nor apparent to the casual observer?
According to Wilson,3 people with unseen disabilities often are viewed as not having a disability at all, simply because they do not look out of the ordinary. Nevertheless, 96% of people with chronic medical conditions live with an illness that is invisible.4 To some extent, the past limitations in third-party coverage for mental health services could be explained by the fact that mental illness may well have been one of those invisible and unseen disabilities. In addition, before deinstitutionalization and mainstreaming individuals with mental illness in community settings, significant numbers were housed in state institutions; almost ‘‘out of sight and out of mind.’’ But this is about to change. MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
In October 2008, the Mental Health Parity and Addiction Equity Act was signed into law. It will end health insurance benefits inequity between mental health/substance
MENTAL ILLNESS IS ALSO A DISABILITY—EVEN FOR CHILDREN
Steven P. Perlman Steven P. Perlman, DDS, MScD Steven P. Perlman is the Global Clinical Director of the Special Olympics, Special Smiles program and is Clinical Professor of Pediatric Dentistry at The Boston University Goldman School of Dental Medicine, Boston, MA. Dr. Perlman is in private pediatric dental practice in Lynn, MA.
use disorders and medical/surgical benefits for group health plans with more than 50 employees.5 When the legislation went into effect on January 1, 2010, it began to cover 82 million individuals in selfinsured employer health plans that were not governed by state parity laws, and another 31 million in plans that were subject to state regulations.6 In other words, deductibles, copayments, covered hospital days, and any limits on outpatient treatment must be identical for mental health/substance abuse coverage and the wide ranging services for medical/surgical treatment. The change also brought parity to millions of individuals, covered through Employee Retirement Income Security Act (ERISA) plans; this federal law sets minimum standards for pension plans in private industry.7,8 Numbers and Proportions
According to a WebMD article, about 20% of American children suffer from a diagnosable mental illness during a given year, according to the US Surgeon General, and nearly 5 million children and adolescents suffer from a serious mental illness (one that significantly interferes with their day-to-day life.9 In addition, ‘‘an estimated 26.2% of Americans ages 18 and older. suffer from a diagnosable mental disorder in a given year.this figure translates to 57.7 million people.’’10 Even though mental disorders are widespread in the adult population, the main burden of illness is concentrated in a much smaller proportion—about 6%, or 1 in 17—who suffer from a serious mental illness.11 The World Health Organization has indicated that mental disorders are the leading cause of disability in the US and Canada for individuals between 15 and 44 years
30
of age.12 Nearly half (45%) of those with any mental disorder meet the criteria for two or more disorders, with severity strongly related to comorbidity.11 In the United States, mental disorders are categorized based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The manual is published by the American Psychiatric Association and covers all mental health disorders for both children and adults. It also lists known causes of these disorders, statistics in terms of gender, age at onset, and prognosis, and research concerning the optimal treatment approaches.13 Mental illnesses encompass the following: Anxiety—Forty million adults (18% of the US population) suffer from anxiety disorders that include panic disorder, obsessive compulsive disorder, posttraumatic stress disorder, social phobia, and specific phobias (e.g., fear of height and agoraphobia).11 Mood disorders—Approximately 20.9 million adults, or about 9.5% of the US population 18 years of age and older. Depression—The leading cause of disability in the United States for individuals 15 to 44 years of age, depression affects 14.8 million adults. It is more prevalent in woman than men. Bipolar disorder—Bipolar disorder affects 5.7 million adults, or about 2.6% of the population 18 years of age and older in a given year. Suicide—In 2004, 32,439 people died by suicide. More than 90% of the people who killed themselves had a diagnosable mental disorder. Four times as many men as women die by suicide. However, women attempt suicide two to three times as often as men. Attention deficit hyperactivity disorder (ADHD)—ADHD is one of the most common mental
Alpha Omegan Volume 103 Number 1
MENTAL ILLNESS IS ALSO A DISABILITY—EVEN FOR CHILDREN disorders in children and adolescents, and it also affects an estimated 4.1% of adults.
The list continues on and on to include schizophrenia (approximately 2.4 million adults have this disorder), obsessive compulsive disorder, social phobia, eating disorders, autism (an estimate of 1 in 150 births; up to 500,000 individuals between the ages of newborn to 21 years have an autism spectrum disorder), and Alzheimer disease (estimated to affect 4.5 million adults and continuing to increase as the aging population increases).10,11,13-15 The emphasis on mental illness should not overshadow the second component of the Mental Health Parity and Addiction Equity Act. In 2007, 114.3 million individuals (46.1% of the population 12 years of age and older) reported having used illicit drugs during their life, 35.7 million (14.4%) used illicit drugs in the past year, and 19.9 million (8.0%) used illicit drugs during the past month.16 Children with Mental Illness
Childhood and adolescence are marked by dramatic changes in physical, cognitive, and social– emotional skills and capabilities. According to the US Surgeon General, the normally developing child hardly stays the same long enough to make stable measurements.17 The criteria used for evaluating adult illness can be difficult to apply to children and adolescents when the signs and symptoms of mental disorders are often also the characteristic of normal development. For example, a temper tantrum could be expected behavior in a young child, but not an adult.17 At some point, however, serious deviations from expected development would need to
be considered as potential indications of mental disorders. Symptoms of mental illness in children may include an inability to cope with daily problems and activities, changes in sleeping and/ or eating activities, excessive complaints of physical ailments, defying authority, skipping school, stealing or damaging property, issue related to losing or gaining weight, longlasting negative moods, hyperactivity, persistent nightmares, and hearing voices or seeing things that are not there.18 It is estimated that almost 21% of US children 9 to 17 years of age have a diagnosable mental or addictive disorder associated with at least minimum impairment. These include anxiety disorder (13%), mood disorder (6.2%), disruptive disorders (10.3%), and substance use disorders (2%). When diagnostic criteria require the presence of significant function impairment, estimates drop to 11% of the child population. This estimate translates to a total of 4 million youngsters who suffer from a major mental illness that results in a significant impairment at home, at school, and with peers. When extreme functional impairment is the criterion, the estimates drop to 5% of the youth population.17 The need for parity in mental health and general medical services for youngsters is exemplified in juvenile dentition centers. These facilities are designed to care for children who have been charged with crimes and those awaiting court hearings or placement. Children are at increased risk of self-harm and violence. Burley writes that the rate of suicide among juveniles while incarcerated is four times that of youth overall.19 Each night, nearly 2,000 youth wait in detention for community mental services, representing 7% of all youth
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in juvenile detention, and a quarter of the facilities surveyed reported that they provide no or poor mental health services.19 The juvenile detention facilities spend an estimated $100 million each year to house youth who are waiting for mental health services.19 Diagnosis and treatment are based on a collaborative process that should involve mental health personnel, the child’s family, and school-based or other health care personnel and the child. The real tragedy is that most children and adolescents with psychiatric disorders still do not get the help they need. It is easy to overlook the seriousness of childhood mental disorders.20 In addition, the contributing current reality of limited numbers of psychiatrists, psychologists, and psychopharmacologists providing care to youngsters may be moderated as a result of the improvement of third party financial support taking place under the aegis of the Mental Health Parity and Addiction Equity Act. Medications that may help include the following: Stimulants—Methylphenidate and amphetamine are the most widely researched and commonly prescribed treatments for children with ADHD. They diminish motor activity and impulsive behavior seen in ADHD and allow the child to sustain attention and improve physical coordination. Side effects may include insomnia, weight loss, decreased appetite, abdominal pain, and headaches.20 Antidepressants—Selective serotonin reuptake inhibitors (SSRIs) affect the chemicals that nerves in the brain use to send messages to one another. These neurotransmitters are released by one nerve and taken up by other nerves. Neurotransmitters that are not taken up by other nerves are taken up by
31
MENTAL ILLNESS IS ALSO A DISABILITY—EVEN FOR CHILDREN the same nerves that released them, a process called ‘‘reuptake.’’ SSRIs work by inhibiting the reuptake of serotonin, an action that allows more serotonin to be available to be taken up by other nerves.21 The SSRIs—fluoxentine, seroxetine, fluvoxamin, and citalopram—are the second most prescribed psychotropic medications, after stimulants for children. They are effective for the treatment of severe and persistent depression and anxiety disorder, such as obsessive compulsive disorder and panic attacks in children and adolescents.20 Antianxiety medications—Anxiety is the most common mental health problem that occurs in children and adolescents. It often is treated with a group of antianxiety medications called benzodiazepines: diazepam, clonazepam and alprazolam, and beta blockers.20 Antipsychotic medications—The principle categories of psychotic illness that affect children are schizophrenia and bipolar disorder, both of which are chronic and disabling disorders. The antipsychotic medication controls symptoms of agitation, aggression, and self-injurious behavior in children with severe developmental disorders (including intellectual disabilities, autism, and autism spectrum disorders).20
The Dental Practitioner’s Perspective
A fourth-year dental student recently approached us for advice with his problem. ‘‘I have a patient who is weird, maybe even mentally ill; how do I get rid of her?’’ We responded with the Socratic retort, ‘‘How would you handle such an issue in your practice, next year?’’ Dentists in local communities increasingly may be placed in the position of our fourth-year student as
32
a consequence of: (1) the enactment of legislation to eliminate health insurance benefit inequity between mental health/substance use disorders and medical/surgical benefits, (2) deinstitutionalization and mainstreaming of individuals with mental and physical disabilities into community settings with the need for services by local practitioners, and (3) the increasing numbers of youngsters and the elderly diagnosed (and not specifically diagnosed) with mental illnesses in families currently being treated by practitioners. As to the ‘‘addiction equity’’ component of the new parity law, the 2007 ADA Survey of Current Issues in Dentistry reported that only onethird of dentists reported they were ‘‘very adequately trained’’ in recognizing and managing substance abuse patients, less than half (47.6%) asked their patients about illegal substance use, only 8.3% of dentists reported they felt very comfortable asking patients about the use of illegal substances, and onequarter (26.3%) indicated that they knew or suspected an employee of substance abuse.22 Whether the patient is a child or an adult, the care of the individual with what may appear to be a mental health disability and/or a situation of substance abuse should be based on a collaborative process that would involve mental health personnel, the individual patient and, when possible, the patient’s family. All parties involved in the care of individuals with mental illness must maintain vigilance regarding the child’s and adult’s potential for self-medication with over the counter items and/or noncompliance with the prescribed medication regimen. The critical factor is to recognize that, as with all patients with special health care
needs, persons with mental illness must be treated as individuals with their particular disabilities and not in terms of generalities for patients with a label of ‘‘mental illness.’’ It also could be possible that the stigma of mental illness may have faded as people see members of the armed forces returning from Iraq and Afghanistan with serious mental problems.23 It is hoped that the stigma of receiving treatment for mental illness will also fade with the enactment of the Mental Health Parity and Addiction Equity Act. References 1. Americans with Disabilities Act website. Americans with Disabilities Act of 1990, as amended. Website: http://www.ada. gov/pubs/ada.htm#Anchor-Sec-47857 Accessed December 26, 2008. 2. Waldman HB, Cannella D, Perlman SP. Invisible and unseendisabilities. EP Magazine 2009;39:84–7. 3. Wilson E. Struggles associated with an invisible disability. Website: http//www. helium.com/items/734213-strugglesassociated-with-an-invisible-disability Accessed November 24, 2008. 4. Headache Adviser website. Chronic illness can be invisible. Website: http:// www.headache-adviser.com/chronicillness.html Accessed December 26, 2008. 5. Association of University Center on Disabilities website. Summary of The Paul Wellstone and Pete Domenici Mental health Parity and Addiction Equity Act of 2008. Website: http://www.aucd. org/docs/parityequityact2008.doc Accessed December 24, 2008. 6. Mental Health America website. Victory for parity and justice for Americans. Website: http://www.nmha.org/go/action/ policy-issues-a-z/parity Accessed December 24, 2008. 7. US Department of Labor website. The Employee Retirement Income Security Act (ERISA). Website: http://www.dol. gov/compliance/laws/comp-erisa.htm Accessed December 24, 2008. 8. Shute N. Equal coverage for mental-health care. US News and World Report. Web site: http://health.usnews. com/articles/health/brain-and-behavior/
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MENTAL ILLNESS IS ALSO A DISABILITY—EVEN FOR CHILDREN
9.
10.
11.
12.
13.
2008/10/30/equal-coverage-for-mentalhealth-care.html Accessed December 22, 2008. WebMD. Mental health: mental illness in children. Website: http://www.webmd. com/anxiety-panic/mental-health-illnessin-children Accessed December 24, 2008. National Institute of Mental Health website. The numbers count: mental disorder in America. Web site: http://www. nimh.nih.gov/health/publications/thenumbers-count-mental-disorders-inamerica.shtml Accessed December 23, 2008. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry 2005;62:617–27. The World Health Organization. The World Health Report: changing history, Annex Table 3: Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, estimates for 2002. Geneva, WHO, 2004. AllPsych online website. Psychiatric disorders. Website: http://allpsych.com/
14.
15.
16.
17.
18.
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disorders/dsm.html Accessed December 23, 2008. Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, Boyle C, Murphy C. Prevalence of autism in a US metropolitan area. JAMA 2003;289:49–55. eNotAlone website. Centers for Disease Control and Prevention. Autism: how common are autism spectrum disorders (ASD)? Website: http://www.enotalone. com/article/6965.html Accessed July 8, 2008. Department of Health and Human Services. 2007 national survey on drug use and health. Website: http://www. drugabusestatistics.samhsa.gov/NSDUH/ 2k7NSDUH/tabs/Sect1peTabs1to46.htm #Tab1.1A Accessed December 29, 2008. US Surgeon General website. Mental health: A report of the Surgeon General. Chapter 3: children and mental health. Website: http://www.surgeongeneral.gov/ library/mentalhealth/chapter3/sec1.html Accessed December 24, 2008. WebMD. Mental health: mental illness in children. Website: http://www.wemd. com/anxiety-panic/mental-health-illnessin-children Accessed December 24, 2008.
19. Burley C. The Bazelon Center for Mental Health Law. Thousands of children with mental illness warehoused in juvenile detention centers awaiting mental health services. Web site:http://www. bazelon.org/newsroom/archive/2004/77-04jjhearing.htm Accessed December 22, 2008. 20. American Psychiatric Association website. Health minds. Health lives. Website: http://www.healthyminds.org/child mentalillnessmedicine.cfm Accessed Decmeber 26, 2008. 21. MedicineNet.com website. Definition of selective serotonin reuptake inhibitor. Website: http://www.medterms.com/ script/main/art.asp?articlekey¼10864 Accessed December 25, 2008. 22. Survey Center. 2007 Survey of current issues in dentistry: physical well-being and substance abuse. Chicago, American Dental Association, 2008. 23. Pear R. Bailout provides more mental health coverage. NY Times, October 5, 2008. Website: http://www.nytimes. com/2008/10/06/washington/06mental. html?_r¼1 Accessed December 24, 2008.
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H. Barry Waldman
Dolores L. Cannella
H. Barry Waldman, DDS, MPH, PhD Dr. H. Barry Waldman is a Distinguished Teaching Professor of the State University of New York. He was the first faculty member of the School of Dental Medicine at Stony Brook where he has served for almost 40 years in numerous roles, including Department Chair and Assistant Dean. He has published 900 monograph and articles in international, national and regional publications evaluating health delivery and social issues, including manpower, health economics, delivery modalities, and quality assessment; with particular emphasis in the issues facing the delivery of health services to youngsters and older patients with special health care needs. Together with Dr. Perlman, he initiated the changes in the accreditation process that now requires all schools of dentistry and dental hygiene to provide training for students in the care of patients with special needs. Dolores L. Cannella, PhD Dolores Cannella is an Assistant Professor and Director of Behavioral Sciences at Stony Brook University, School of Dental Medicine. She lectures on a variety of topics relevant to the doctor–patient relationship, such as health literacy, cultural competency, dental anxiety, and health behavior change. Her research interests involve employing social psychological theories to investigate oral health promotion and disparities in oral health care services. She is the Coinvestigator of Stony Brook’s Pregnancy Project, whose current aim is to increase access to oral health care services for disadvantaged and underserved pregnant women.
Mental Illness is Also A Disability—Even for Children H. Barry Waldman, DDS, MPH, PhD, Dolores L. Cannella, PhD, and Steven P. Perlman, DDS, MScD
T
he enactment of the 2008 Mental Health Parity and Addiction Equity Act was a major step in an effort to eliminate health insurance benefit inequity between mental health/substance use disorders and medical/ surgical benefits. But individuals and their families may not seek needed care because mental illness could still remain an unrecognized disability, especially among children. The extent of the problem, related symptoms, some approaches for care, and the involvement of dental practitioners are considered below. ‘‘The Americans with Disabilities Act (ADA) has a three-part definition of disability. Under ADA, an individual with a disability is a person who: (a) has a physical or mental impairment that substantially limits one or more major life activities; or (b) has a record of such impairment; or (c) is regarded as having such an impairment.’’1 ‘‘Have you ever seen someone park a car in a spot for individuals with disabilities, hang a parking pass on the mirror and then walk away? Did you ever then think to yourself, ‘They don’t look disabled’? Actually, what do individuals with a disability look like?’’2
Most people are able to recognize individuals with ‘‘obvious’’ physical disabilities. To a far greater extent than in the past, we recognize ‘‘viewable disabilities’’ and make needed accommodations—in school and work settings, an increase of ramps for architectural barriers, street curb cuts, enunciators in elevators, and beyond. But what of those disabilities that are not observable, nor apparent to the casual observer?
According to Wilson,3 people with unseen disabilities often are viewed as not having a disability at all, simply because they do not look out of the ordinary. Nevertheless, 96% of people with chronic medical conditions live with an illness that is invisible.4 To some extent, the past limitations in third-party coverage for mental health services could be explained by the fact that mental illness may well have been one of those invisible and unseen disabilities. In addition, before deinstitutionalization and mainstreaming individuals with mental illness in community settings, significant numbers were housed in state institutions; almost ‘‘out of sight and out of mind.’’ But this is about to change. MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
In October 2008, the Mental Health Parity and Addiction Equity Act was signed into law. It will end health insurance benefits inequity between mental health/substance
MENTAL ILLNESS IS ALSO A DISABILITY—EVEN FOR CHILDREN
Steven P. Perlman Steven P. Perlman, DDS, MScD Steven P. Perlman is the Global Clinical Director of the Special Olympics, Special Smiles program and is Clinical Professor of Pediatric Dentistry at The Boston University Goldman School of Dental Medicine, Boston, MA. Dr. Perlman is in private pediatric dental practice in Lynn, MA.
use disorders and medical/surgical benefits for group health plans with more than 50 employees.5 When the legislation went into effect on January 1, 2010, it began to cover 82 million individuals in selfinsured employer health plans that were not governed by state parity laws, and another 31 million in plans that were subject to state regulations.6 In other words, deductibles, copayments, covered hospital days, and any limits on outpatient treatment must be identical for mental health/substance abuse coverage and the wide ranging services for medical/surgical treatment. The change also brought parity to millions of individuals, covered through Employee Retirement Income Security Act (ERISA) plans; this federal law sets minimum standards for pension plans in private industry.7,8 Numbers and Proportions
According to a WebMD article, about 20% of American children suffer from a diagnosable mental illness during a given year, according to the US Surgeon General, and nearly 5 million children and adolescents suffer from a serious mental illness (one that significantly interferes with their day-to-day life.9 In addition, ‘‘an estimated 26.2% of Americans ages 18 and older. suffer from a diagnosable mental disorder in a given year.this figure translates to 57.7 million people.’’10 Even though mental disorders are widespread in the adult population, the main burden of illness is concentrated in a much smaller proportion—about 6%, or 1 in 17—who suffer from a serious mental illness.11 The World Health Organization has indicated that mental disorders are the leading cause of disability in the US and Canada for individuals between 15 and 44 years
30
of age.12 Nearly half (45%) of those with any mental disorder meet the criteria for two or more disorders, with severity strongly related to comorbidity.11 In the United States, mental disorders are categorized based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The manual is published by the American Psychiatric Association and covers all mental health disorders for both children and adults. It also lists known causes of these disorders, statistics in terms of gender, age at onset, and prognosis, and research concerning the optimal treatment approaches.13 Mental illnesses encompass the following: Anxiety—Forty million adults (18% of the US population) suffer from anxiety disorders that include panic disorder, obsessive compulsive disorder, posttraumatic stress disorder, social phobia, and specific phobias (e.g., fear of height and agoraphobia).11 Mood disorders—Approximately 20.9 million adults, or about 9.5% of the US population 18 years of age and older. Depression—The leading cause of disability in the United States for individuals 15 to 44 years of age, depression affects 14.8 million adults. It is more prevalent in woman than men. Bipolar disorder—Bipolar disorder affects 5.7 million adults, or about 2.6% of the population 18 years of age and older in a given year. Suicide—In 2004, 32,439 people died by suicide. More than 90% of the people who killed themselves had a diagnosable mental disorder. Four times as many men as women die by suicide. However, women attempt suicide two to three times as often as men. Attention deficit hyperactivity disorder (ADHD)—ADHD is one of the most common mental
Alpha Omegan Volume 103 Number 1
MENTAL ILLNESS IS ALSO A DISABILITY—EVEN FOR CHILDREN disorders in children and adolescents, and it also affects an estimated 4.1% of adults.
The list continues on and on to include schizophrenia (approximately 2.4 million adults have this disorder), obsessive compulsive disorder, social phobia, eating disorders, autism (an estimate of 1 in 150 births; up to 500,000 individuals between the ages of newborn to 21 years have an autism spectrum disorder), and Alzheimer disease (estimated to affect 4.5 million adults and continuing to increase as the aging population increases).10,11,13-15 The emphasis on mental illness should not overshadow the second component of the Mental Health Parity and Addiction Equity Act. In 2007, 114.3 million individuals (46.1% of the population 12 years of age and older) reported having used illicit drugs during their life, 35.7 million (14.4%) used illicit drugs in the past year, and 19.9 million (8.0%) used illicit drugs during the past month.16 Children with Mental Illness
Childhood and adolescence are marked by dramatic changes in physical, cognitive, and social– emotional skills and capabilities. According to the US Surgeon General, the normally developing child hardly stays the same long enough to make stable measurements.17 The criteria used for evaluating adult illness can be difficult to apply to children and adolescents when the signs and symptoms of mental disorders are often also the characteristic of normal development. For example, a temper tantrum could be expected behavior in a young child, but not an adult.17 At some point, however, serious deviations from expected development would need to
be considered as potential indications of mental disorders. Symptoms of mental illness in children may include an inability to cope with daily problems and activities, changes in sleeping and/ or eating activities, excessive complaints of physical ailments, defying authority, skipping school, stealing or damaging property, issue related to losing or gaining weight, longlasting negative moods, hyperactivity, persistent nightmares, and hearing voices or seeing things that are not there.18 It is estimated that almost 21% of US children 9 to 17 years of age have a diagnosable mental or addictive disorder associated with at least minimum impairment. These include anxiety disorder (13%), mood disorder (6.2%), disruptive disorders (10.3%), and substance use disorders (2%). When diagnostic criteria require the presence of significant function impairment, estimates drop to 11% of the child population. This estimate translates to a total of 4 million youngsters who suffer from a major mental illness that results in a significant impairment at home, at school, and with peers. When extreme functional impairment is the criterion, the estimates drop to 5% of the youth population.17 The need for parity in mental health and general medical services for youngsters is exemplified in juvenile dentition centers. These facilities are designed to care for children who have been charged with crimes and those awaiting court hearings or placement. Children are at increased risk of self-harm and violence. Burley writes that the rate of suicide among juveniles while incarcerated is four times that of youth overall.19 Each night, nearly 2,000 youth wait in detention for community mental services, representing 7% of all youth
Alpha Omegan Volume 103 Number 1
in juvenile detention, and a quarter of the facilities surveyed reported that they provide no or poor mental health services.19 The juvenile detention facilities spend an estimated $100 million each year to house youth who are waiting for mental health services.19 Diagnosis and treatment are based on a collaborative process that should involve mental health personnel, the child’s family, and school-based or other health care personnel and the child. The real tragedy is that most children and adolescents with psychiatric disorders still do not get the help they need. It is easy to overlook the seriousness of childhood mental disorders.20 In addition, the contributing current reality of limited numbers of psychiatrists, psychologists, and psychopharmacologists providing care to youngsters may be moderated as a result of the improvement of third party financial support taking place under the aegis of the Mental Health Parity and Addiction Equity Act. Medications that may help include the following: Stimulants—Methylphenidate and amphetamine are the most widely researched and commonly prescribed treatments for children with ADHD. They diminish motor activity and impulsive behavior seen in ADHD and allow the child to sustain attention and improve physical coordination. Side effects may include insomnia, weight loss, decreased appetite, abdominal pain, and headaches.20 Antidepressants—Selective serotonin reuptake inhibitors (SSRIs) affect the chemicals that nerves in the brain use to send messages to one another. These neurotransmitters are released by one nerve and taken up by other nerves. Neurotransmitters that are not taken up by other nerves are taken up by
31
MENTAL ILLNESS IS ALSO A DISABILITY—EVEN FOR CHILDREN the same nerves that released them, a process called ‘‘reuptake.’’ SSRIs work by inhibiting the reuptake of serotonin, an action that allows more serotonin to be available to be taken up by other nerves.21 The SSRIs—fluoxentine, seroxetine, fluvoxamin, and citalopram—are the second most prescribed psychotropic medications, after stimulants for children. They are effective for the treatment of severe and persistent depression and anxiety disorder, such as obsessive compulsive disorder and panic attacks in children and adolescents.20 Antianxiety medications—Anxiety is the most common mental health problem that occurs in children and adolescents. It often is treated with a group of antianxiety medications called benzodiazepines: diazepam, clonazepam and alprazolam, and beta blockers.20 Antipsychotic medications—The principle categories of psychotic illness that affect children are schizophrenia and bipolar disorder, both of which are chronic and disabling disorders. The antipsychotic medication controls symptoms of agitation, aggression, and self-injurious behavior in children with severe developmental disorders (including intellectual disabilities, autism, and autism spectrum disorders).20
The Dental Practitioner’s Perspective
A fourth-year dental student recently approached us for advice with his problem. ‘‘I have a patient who is weird, maybe even mentally ill; how do I get rid of her?’’ We responded with the Socratic retort, ‘‘How would you handle such an issue in your practice, next year?’’ Dentists in local communities increasingly may be placed in the position of our fourth-year student as
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a consequence of: (1) the enactment of legislation to eliminate health insurance benefit inequity between mental health/substance use disorders and medical/surgical benefits, (2) deinstitutionalization and mainstreaming of individuals with mental and physical disabilities into community settings with the need for services by local practitioners, and (3) the increasing numbers of youngsters and the elderly diagnosed (and not specifically diagnosed) with mental illnesses in families currently being treated by practitioners. As to the ‘‘addiction equity’’ component of the new parity law, the 2007 ADA Survey of Current Issues in Dentistry reported that only onethird of dentists reported they were ‘‘very adequately trained’’ in recognizing and managing substance abuse patients, less than half (47.6%) asked their patients about illegal substance use, only 8.3% of dentists reported they felt very comfortable asking patients about the use of illegal substances, and onequarter (26.3%) indicated that they knew or suspected an employee of substance abuse.22 Whether the patient is a child or an adult, the care of the individual with what may appear to be a mental health disability and/or a situation of substance abuse should be based on a collaborative process that would involve mental health personnel, the individual patient and, when possible, the patient’s family. All parties involved in the care of individuals with mental illness must maintain vigilance regarding the child’s and adult’s potential for self-medication with over the counter items and/or noncompliance with the prescribed medication regimen. The critical factor is to recognize that, as with all patients with special health care
needs, persons with mental illness must be treated as individuals with their particular disabilities and not in terms of generalities for patients with a label of ‘‘mental illness.’’ It also could be possible that the stigma of mental illness may have faded as people see members of the armed forces returning from Iraq and Afghanistan with serious mental problems.23 It is hoped that the stigma of receiving treatment for mental illness will also fade with the enactment of the Mental Health Parity and Addiction Equity Act. References 1. Americans with Disabilities Act website. Americans with Disabilities Act of 1990, as amended. Website: http://www.ada. gov/pubs/ada.htm#Anchor-Sec-47857 Accessed December 26, 2008. 2. Waldman HB, Cannella D, Perlman SP. Invisible and unseendisabilities. EP Magazine 2009;39:84–7. 3. Wilson E. Struggles associated with an invisible disability. Website: http//www. helium.com/items/734213-strugglesassociated-with-an-invisible-disability Accessed November 24, 2008. 4. Headache Adviser website. Chronic illness can be invisible. Website: http:// www.headache-adviser.com/chronicillness.html Accessed December 26, 2008. 5. Association of University Center on Disabilities website. Summary of The Paul Wellstone and Pete Domenici Mental health Parity and Addiction Equity Act of 2008. Website: http://www.aucd. org/docs/parityequityact2008.doc Accessed December 24, 2008. 6. Mental Health America website. Victory for parity and justice for Americans. Website: http://www.nmha.org/go/action/ policy-issues-a-z/parity Accessed December 24, 2008. 7. US Department of Labor website. The Employee Retirement Income Security Act (ERISA). Website: http://www.dol. gov/compliance/laws/comp-erisa.htm Accessed December 24, 2008. 8. Shute N. Equal coverage for mental-health care. US News and World Report. Web site: http://health.usnews. com/articles/health/brain-and-behavior/
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2008/10/30/equal-coverage-for-mentalhealth-care.html Accessed December 22, 2008. WebMD. Mental health: mental illness in children. Website: http://www.webmd. com/anxiety-panic/mental-health-illnessin-children Accessed December 24, 2008. National Institute of Mental Health website. The numbers count: mental disorder in America. Web site: http://www. nimh.nih.gov/health/publications/thenumbers-count-mental-disorders-inamerica.shtml Accessed December 23, 2008. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry 2005;62:617–27. The World Health Organization. The World Health Report: changing history, Annex Table 3: Burden of disease in DALYs by cause, sex, and mortality stratum in WHO regions, estimates for 2002. Geneva, WHO, 2004. AllPsych online website. Psychiatric disorders. Website: http://allpsych.com/
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disorders/dsm.html Accessed December 23, 2008. Yeargin-Allsopp M, Rice C, Karapurkar T, Doernberg N, Boyle C, Murphy C. Prevalence of autism in a US metropolitan area. JAMA 2003;289:49–55. eNotAlone website. Centers for Disease Control and Prevention. Autism: how common are autism spectrum disorders (ASD)? Website: http://www.enotalone. com/article/6965.html Accessed July 8, 2008. Department of Health and Human Services. 2007 national survey on drug use and health. Website: http://www. drugabusestatistics.samhsa.gov/NSDUH/ 2k7NSDUH/tabs/Sect1peTabs1to46.htm #Tab1.1A Accessed December 29, 2008. US Surgeon General website. Mental health: A report of the Surgeon General. Chapter 3: children and mental health. Website: http://www.surgeongeneral.gov/ library/mentalhealth/chapter3/sec1.html Accessed December 24, 2008. WebMD. Mental health: mental illness in children. Website: http://www.wemd. com/anxiety-panic/mental-health-illnessin-children Accessed December 24, 2008.
19. Burley C. The Bazelon Center for Mental Health Law. Thousands of children with mental illness warehoused in juvenile detention centers awaiting mental health services. Web site:http://www. bazelon.org/newsroom/archive/2004/77-04jjhearing.htm Accessed December 22, 2008. 20. American Psychiatric Association website. Health minds. Health lives. Website: http://www.healthyminds.org/child mentalillnessmedicine.cfm Accessed Decmeber 26, 2008. 21. MedicineNet.com website. Definition of selective serotonin reuptake inhibitor. Website: http://www.medterms.com/ script/main/art.asp?articlekey¼10864 Accessed December 25, 2008. 22. Survey Center. 2007 Survey of current issues in dentistry: physical well-being and substance abuse. Chicago, American Dental Association, 2008. 23. Pear R. Bailout provides more mental health coverage. NY Times, October 5, 2008. Website: http://www.nytimes. com/2008/10/06/washington/06mental. html?_r¼1 Accessed December 24, 2008.
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