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PEDIATRICS Vol. 108 No. 4 October 2001, pp. 1025-1029
The numbers of children, adolescents, and families
affected by substance abuse have sharply increased since the early
1990s. The American Academy of Pediatrics recognizes the scope and
urgency of this problem and has developed this policy statement for
consideration by Congress, federal and state agencies, employers,
national organizations, health care professionals, health insurers,
managed care organizations, advocacy groups, and families.
ABSTRACT
Top
Abstract
Introduction
References
Leading the list of Americans' concerns for children is
drug abuse, according to a 1997 Harvard study.1 The
numbers of children, adolescents, and families affected by substance
abuse have sharply increased since the early 1990s.2
Unfortunately, the availability of and financing for substance abuse
prevention, assessment, and treatment have not kept pace with the needs
of young people. Access to substance abuse services has decreased during the past decade because of inadequate insurance coverage, managed care controls, and low reimbursement rates. Although there are
no national estimates of unmet need for substance abuse services for
children, the surgeon general estimated that as many as 75% to 80% of
children who are in need of mental health treatment fail to receive
it.3 The consequences of failing to intervene early and
not providing age-appropriate substance abuse and mental health
treatment are substantial and long-term.
This policy statement includes a summary of the prevalence of substance
abuse among children and adolescents along with a review of financing
problems experienced by those who are insured through private health
insurance, Medicaid, and the State Children's Health Insurance Program
(SCHIP), and those who are uninsured. The statement concludes with
specific recommendations for financing substance abuse prevention,
assessment, and treatment for children and adolescents. By necessity,
these recommendations incorporate mental health problems and
interventions because of the high prevalence of comorbid psychiatric
disorders among children with substance abuse problems.
Substance abuse by young people has increased in the past decade,
and it is occurring at younger ages. According to results from the
Monitoring the Future Study conducted in 1999 at the University of Michigan Institute for Social Research, 33% of 12th graders and 9% of eighth graders reported being drunk 1 or more times
during the last 30 days.2 As many as 23% of high school
seniors and 10% of eighth graders reported using marijuana in the last
30 days, up from 14% and 3%, respectively, in 1991. The percentage of
adolescents who reported using hallucinogens, lysergic acid
diethylamide (LSD), phencyclidine hydrochloride (PCP), cocaine and
crack cocaine, heroin, amphetamines, methamphetamines, barbiturates,
and tranquilizers also increased between 1991 and 1999. In addition,
cigarette use among adolescents, which is a risk factor for use of
marijuana and other illicit drugs, also markedly increased during this
decade. In 1999, 35% of 12th graders reported smoking cigarettes
during the last 30 days, up from 28% in 1991. Among eighth graders,
the reported 30-day cigarette use rate increased from 14% to 18%.
Epidemiologic data revealed that 9% of adolescent females and 20% of
adolescent males meet adult diagnostic criteria for an alcohol use
disorder.4 Among adolescents and young adults with a
substance abuse disorder, 41% to 65% also have a mental health
disorder.3 The most common of these are depression, conduct disorder, and attention-deficit/hyperactivity disorder (ADHD)
in combination with conduct disorder. ADHD and learning disorders in
combination with depression and anxiety disorders also carry a high
risk of substance abuse. If the significant number of drug-exposed
infants and the 1 in 6 children exposed to substance abuse within their
families are added to these estimates, the size of the population
affected by substance abuse and, therefore, potentially needing
assistance dramatically increases.5
Obtaining accurate estimates of the prevalence of substance abuse among
children and adolescents is very difficult. Most national studies
survey only students, but many high-risk youth do not regularly attend
school and, thus, are not included in these estimates. Other
difficulties in obtaining reliable estimates are the results of
coverage and reimbursement problems. Rather than using a substance abuse diagnosis, health care professionals may be using procedure codes
for treating associated symptoms of substance abuse, such as fatigue,
irritability, weight loss, headache, abdominal pain, or depression. The
lack of use of substance abuse codes may also reflect health care
professionals' attempt to avoid stigmatizing a child. Consequently,
existing prevalence data likely underestimate the scope of the problem.
Data specific to adolescents are limited, but there is growing evidence
that successful early intervention and treatment carries significant
benefit for the individual and society.6 The most
appropriate assessment of costs and benefits of treatment are based on
broader outcome measures rather than abstinence alone. Despite the fact
that there is no single treatment approach that works for all patients,
standard treatments have been shown to produce significant decreases in
drug use and in drug-related problems of crime, family violence,
unemployment, welfare dependence, underachievement, and other
antisocial behaviors.7
Although most families whose children require substance abuse
services experience financial difficulties related to high
out-of-pocket expenses, those who are uninsured are at the greatest
disadvantage. An estimated 14 million or 15.9% of children younger
than 22 years had no health insurance coverage in 1999.8
These families must rely exclusively on publicly funded services
through their state's substance abuse and mental health agencies or
must pay for care themselves. Often, uninsured youth receive
uncompensated hospital and emergency care for acute symptoms only,
which is seldom coordinated with primary care and behavioral health
services. Unfortunately, publicly supported substance abuse and mental
health services are underfunded and are typically available only for youth with serious emotional disturbances whose families meet a certain
income threshold. Many young people, particularly those who are just
beginning to abuse alcohol and other drugs, do not have serious
emotional disturbances and, therefore, do not qualify for state-funded
services. Moreover, children who are privately insured but without
adequate substance abuse and mental health benefits are seldom eligible
for state-funded services.
Most children under age 22 (65.4% or 57.7 million) are privately
insured by plans purchased by their families individually or through
their employers.8 Often, these families rapidly exhaust
their annual and even lifetime allotment of substance abuse benefits
and must pay for needed services themselves or rely exclusively on
self-help organizations, such as Alcoholics Anonymous and Narcotics
Anonymous. Most private health insurance plans impose benefit
limitations and cost-sharing requirements on substance abuse and mental
health services that are greater than those imposed on general medical
services.9,10 For example, coverage of outpatient
substance abuse services, when available, is typically short in
duration and is often capped at an inadequate number of visits. Family
therapy is often excluded. Inpatient substance abuse services are
sometimes excluded altogether or covered only for acute detoxification
purposes. Coverage of prevention, assessment, early intervention,
relapse prevention, crisis intervention, partial hospitalization or day
treatment, and residential care is seldom covered by private plans.
Mental health benefits, however, are often provided somewhat more
generously than are substance abuse benefits.2,11
In addition to benefit limitations, many private insurance plans
require higher copayments or coinsurance in addition to separate deductibles for substance abuse benefits.11 The Mental Health Parity Act of 1996 prohibits plans from imposing higher annual
and lifetime out-of-pocket maximums for mental health services than for
general medical services.12 Although many states have
passed mental health parity legislation, substance abuse parity is
often not included. Thus, many of the gains that have been made in
achieving parity only apply to mental health. This may perpetuate the
pattern of physicians using procedure codes for treating associated
symptoms of substance abuse rather than codes for a substance abuse
diagnosis, which further distorts prevalence statistics. Also, the lack
of specific data furthers the misconception that substance abuse is a
consequence of mental illness rather than a primary disease, a
comorbidity, or a significant precipitant of mental health problems.
Medicaid, the source of insurance for 16.4 million or 18.7% of all
children younger than 22 years, has historically covered fewer
adolescents than younger children.8 Not until the enactment of SCHIP have many states taken the option to expand Medicaid
to cover all adolescents from families with incomes at 100% of the
federal poverty level. Unlike private coverage, Medicaid's benefits
for children and adolescents are comprehensive and cover a continuum of
inpatient and outpatient substance abuse and mental health services.
Although Medicaid benefits are expansive, reimbursement rates have been
very low and, as a result, serve as a disincentive to provide qualified
pediatric and substance abuse services.
Regardless of the source of health insurance coverage, most substance
abuse and mental health services are delivered by managed behavioral
plans, distinct from general managed care plans and primary pediatric
medical care. Although the literature shows that managed behavioral
health plans have provided greater overall access to mental health
services and a greater continuum of care, it also shows that as a
result of tight utilization management, rates of ambulatory visits and
hospitalizations have decreased.3 Pediatricians and other
referring health care providers report persistent problems in obtaining
authorization for substance abuse treatment for children and
adolescents. Often, utilization review criteria address the needs of
adults, and children's conditions must be severe or associated with
comorbidities to warrant extended counseling or hospital stays. For
example, criteria such as chronicity, loss of work, and
adult comorbidities Compounding these difficulties is the overall shortage of ambulatory
and inpatient substance abuse and mental health services for children
and adolescents. Many inpatient facilities have closed during recent
years. These shortages have resulted from many factors, including
historically low rates of reimbursement provided to substance abuse and
mental health professionals. To serve this population effectively is
very labor intensive, and insurance dollars and public funds
consistently fail to provide adequate reimbursement. Also contributing
to payment and service gaps is the fact few insurers recognize the new
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition: Primary Care Version, which was developed jointly by the
pediatric and mental health communities to encourage earlier
identification and primary behavioral interventions.13 In
addition, pediatricians are seldom able to receive reimbursement for
providing counseling and education services to children at high risk of
developing substance abuse problems.
Serious problems exist in the availability and organization of
behavioral health services for the treatment of substance abuse problems among youth. Although there are substantial problems with low
payment and persistent obstacles in gaining access to needed
interventions, pediatricians are in a unique role to identify and
intervene with children and adolescents who have or are at risk of
substance abuse problems.14 In addition, a cadre of
physicians needs to be trained in the field of pediatric addiction medicine. However, the recruitment and retention of pediatricians and
other health care providers in the field of addiction medicine has been
very difficult, which seriously compromises the provision of
high-quality substance abuse care.14
Many changes need to be made to the financing and delivery of
substance abuse care to improve the availability of services for all
children and adolescents. Change in this area, however, is not likely
to occur without the participation of a coalition of national and state
legislators, public purchasers, employers, health professionals,
families, and health services researchers. The American Academy of
Pediatrics, together with other participating behavioral health
organizations and consumer groups, released a consensus statement on
insurance coverage for mental health and substance abuse services for
children and adolescents, which highlights the deterioration of mental
health and substance abuse services and recommends access,
coordination, and monitoring strategies for achieving service
improvements.15 That article and this policy statement on
financing should serve as blueprints for Congress, federal and state
policy-makers, and employers.
The American Academy of Pediatrics recommends that Congress authorize
the Substance Abuse and Mental Health Services Administration to
conduct a comprehensive national study of the supply, distribution, financing, and quality of substance abuse prevention, assessment, and
treatment services for children and adolescents.
Additional recommendations address the needs of all children,
regardless of insurance status. In addition, there are specific recommendations that apply to those with private insurance, those with
Medicaid or SCHIP coverage, and those who are uninsured.
For All Children and Adolescents, Regardless of Insurance Status
INTRODUCTION
Top
Abstract
Introduction
References
PREVALENCE AND IMPACT OF SUBSTANCE ABUSE AMONG CHILDREN AND
ADOLESCENTS
EXTENT OF FINANCING PROBLEMS FOR SUBSTANCE ABUSE SERVICES
which are inappropriate for young peopleare
often used to determine whether substance abuse treatment is medically
necessary. Moreover, many behavioral health plans have closed panels of
mental health professionals with limited pediatric substance abuse
training or experience. Seldom does coordination between primary care
and behavioral health care take place effectively. Problems have also
been reported in sharing medical information between behavioral health
plans and primary care providers.
FINANCING RECOMMENDATIONS
For Privately Insured Children and Adolescents
For Medicaid and SCHIP Insured Children and Adolescents
For Uninsured Children and Adolescents
Committee on Child Health Financing, 2000-2001
Richard P. Nelson, MD, Chairperson
Jeffrey M. Brown, MD, MPH
Wallace D. Brown, MD
Beverly L. Koops, MD
Thomas K. McInerny, MD
John R. Meurer, MD, MM
Maria E. Minon, MD
Mark J. Werner, MD, CPE
Jean A. Wright, MD, MBA
Consultant
Margaret McManus, MHS
Staff
Jean Davis
Committee on Substance Abuse, 2000-2001
Edward A. Jacobs, MD, Chairperson
Alain Joffe, MD, MPH
John R. Knight, MD
John Kulig, MD, MPH
Peter D. Rogers, MD, MPH
Liaisons
Gayle M. Boyd, PhD
National Institute of Alcohol Abuse and Alcoholism
Dorynne Czechowicz, MD
National Institute on Drug Abuse
Deborah Simkin, MD
American Academy of Child and Adolescent Psychiatry
Staff
Karen Smith
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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SCHIP, State Children's Health Insurance Program; LSD, lysergic acid diethylamide; PCP, phencyclidine hydrochloride; ADHD, attention-deficit/hyperactivity disorder.
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REFERENCES |
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Top
Abstract
Introduction
References
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I. Age- and gender-specific
prevalence.
J Child Psychol Psychiatry
1993;
34:851-867 [Medline]This article has been cited by other articles:
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  J. Agley and R. Gassman A State-Based Model of Prevention: Indiana's Example Health Promot Pract, April 1, 2008; 9(2): 199 - 204. [Abstract] [PDF]
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 D. Deck and K. V. Ley Medicaid Eligibility and Access to Mental Health Services Among Adolescents in Substance Abuse Treatment Psychiatr Serv, February 1, 2006; 57(2): 263 - 265. [Abstract] [Full Text] [PDF]
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 P McArdle Substance abuse by children and young people Arch. Dis. Child., August 1, 2004; 89(8): 701 - 704. [Full Text] [PDF]
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R. C. McMillen, J. P. Winickoff, J. D. Klein, and M. Weitzman US Adult Attitudes and Practices Regarding Smoking Restrictions and Child Exposure to Environmental Tobacco Smoke: Changes in the Social Climate From 2000-2001 Pediatrics, July 1, 2003; 112(1): e55 - 60. [Abstract] [Full Text] [PDF]
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