The Economic Disparity of Children's Mental Health Care

Seven-year-old Jarrod was a classic bully. He hit and kicked other children at school when he didn't get what he wanted. He even bit one of his classmates for not giving him a toy. The principal and teacher at Jarrod's school had been very patient with him because they knew that his parents had recently divorced. His mother was going it alone more or less as a single parent, with Jarrod's father having only infrequent visitation. But now the parents of other children were starting to complain about Jarrod's bullying, and his teacher thought he should be evaluated for ADHD or oppositional defiant disorder (ODD). A friend suggested to Jarrod's mother that she try family therapy before seeking a medical evaluation. She checked with her health insurance and found that it would cover family therapy. That is how I met Jarrod and his family.

In the first 50 minute session, the root of the boy's problem became clear. Jarrod confided to me that he was worried about his father because his father cried every time he had to drop him off at his mother's house. "Daddy wants to spend more time with me and mommy won't let him," he continued. I started to get the picture. Jarrod's parents had been through a messy divorce, and they were still squabbling over visitation. And, as often happens in this kind of situation, the parent's hostility toward each other was affecting their son. A young child is closely connected to his family system, and a disturbance in that system can affect the child's behavior and feelings in unexpected ways. Jarrod was feeling his father's pain and acting it out toward everyone around him.

The path of therapy was clear cut. I would have to help the parents renegotiate their post-divorce parenting relationship to something more civil. I met first with Jarrod's mother and a few days later with Jarrod and his father. I could see the joy on Jarrod's face when he saw his father in my office. With tears in his eyes, the father explained that he missed his son terribly and wanted more time with him. He and his ex-wife could not communicate about the subject of visitation without getting embroiled in an unpleasant argument. He felt hopeless. In a separate session, I explained to Jarrod's mother that the visitation issue was affecting her son's behavior. I managed to get her to agree to Jarrod's spending more time with his father. I helped the mother get over her anger at the way her ex-husband had treated her. I met with the mother for two more sessions, and we worked out a new visitation arrangement. After his father began spending more time with him, Jarrod's bullying stopped. His teacher said it was "like night and day." He seemed like a different child.

Because Jarrod's mother had a good job, which provided her with health insurance that covered family counseling, I had time to meet with everyone involved and figure out what to do. Jarrod was fortunate. Other children, whose parents do not have private health insurance, are not so fortunate.

Let us now consider a fictional 7-year-old boy named Charles, whose bullying behavior is almost identical to Jarrod's. His family situation is also similar, with his parents having recently gone through a hostile divorce and his father having little visitation. The difference is that Charles's health coverage is Medicaid. Unlike Jarrod's mother, Charles's mother does not have the option of consulting a family therapist because Medicaid does not cover talk therapy. What Medicaid does cover is psychiatry and psychiatric medication.

When Charles's school complains about the boy's misbehavior, his mother consults a list of Medicaid providers and chooses a child psychiatrist. The doctor meets with Charles and his mother for, at best, 30 minutes, and listens to the story of Charles's aggressive behavior. The psychiatrist then diagnoses Charles with oppositional defiant disorder (ODD) or ADHD, for which he prescribes one or more medications. Even if the psychiatrist preferred a more humanistic approach and believed that talk therapy could have a beneficial effect on Charles, he also knows that Medicaid does not cover talk therapy. He would not have the luxury of delving more deeply into Charles's family story even if he wanted to do so.

Charles would see the psychiatrist for a 15-minute med check every six weeks. In the best case, the medication would sedate the boy and curb his aggressiveness. Ultimately, however, since the real stressor in Charles's family situation is never addressed, medication will not suffice. His aggressiveness eventually re-emerges, and he continues to act out the hostility between his parents. He is labeled a "bully" and a "troublemaker." Without a stable father-figure in his life, he eventually finds his self-identity in a violent gang. After a few years, Charles could well be diagnosed with bipolar disorder and given a much stronger medication. With the family problem at the root of his misbehavior never being addressed, the ending of Charles's story would be quite different from Jarrod's.

The tales of Jarrod and Charles illustrate the grave inequality that exists in the mental health care of America's children. This inequality is one chapter in the larger story of the widening chasm between health services available to the rich and those available to the poor. Charles's story is writ large in the millions of underprivileged children in our country who are diagnosed each year with psychiatric disorders and medicated. No country in the developed world diagnoses and medicates its children in numbers proportionate to the United States, and poor children in our country are given psychotropic drugs four times as often as middle class children.

In my view, the inequality in mental health care for children could be corrected if Medicaid adopted a mental health care model similar to that of health insurance companies. Many private health insurers have realized the effectiveness of brief talk therapy as an adjunct to psychiatry for problems of children. Six or eight sessions of family therapy could well resolve Charles's bullying behavior without either the risks or the expense of psychiatric medications. With the family system problem being addressed and resolved in therapy, Charles's story would have a happy ending like Jarrod's.