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Too many meds, too little testing

May 20, 2010
by Jerrold Pollak, PhD, ABPP, ABN
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Psychologist calls for better ways to fund comprehensive evaluations for schoolkids

The number of children/adolescents diagnosed with neurodevelopmental and neuropsychiatric disorders has risen dramatically since the mid-1990s. This significant increase in mental health related diagnoses has coincided with the widespread use of psychotropic medications, often multiple agents (“drug cocktails”), as the mainstay of intervention.

Research supports both the “underdiagnosis” and “overdiagnosis” of mental health disorders in children/adolescents.1 With the exception of the good empirical support for the efficacy of medication management for attention deficit disorder without significant co-morbidity, the scientific debate also continues as to the effectiveness of psychopharmacologic treatment across the diagnostic spectrum.

One thing is clear: Most children/ adolescents with one or more mental health diagnoses who are treated frequently for extended periods with various “drug cocktails” are not receiving intensive diagnostic evaluations of their clinical status and psychoeducational needs to better determine appropriate intervention/treatment.

More specifically, “drive-by” assessments in primary care and mental health settings have become an acceptable standard of care while comprehensive psychological/neuropsychological testing and psychoeducational evaluation, known to be of considerable clinical utility in the assessment of mental disorders in children/adolescents, is clearly the exception to the rule.

There are several reasons for the significant underutilization of detailed psycho-diagnostic testing. First, many parents as well as medical and mental healthcare professionals have limited knowledge of psychometric assessment.

A second factor is the steadily worsening “pass the buck” phenomena in special education and behavioral healthcare. Public schools are overwhelmed by the number of students referred for evaluation and special education departments do not have the staffing or expertise to perform in-depth assessments in most cases. In addition, syndromes like attention deficit disorder, which are arguably better conceptualized as neurodevelopmental/psychoeducational conditions rather than medical illnesses, continue to fall under the purview of physicians for diagnosis and treatment, which limits the role school departments can play with respect to assessment and intervention.

Third, the managed mental healthcare industry remains reluctant to approve authorization for testing conducted by community-based psychologists. In particular, authorization for evaluation of neurodevelopmental conditions–learning disorders and attention deficit disorder (especially when the latter is the exclusive or primary rule out diagnosis)—are routinely denied. Most insurance plans also do not cover the cost of record reviews (which are extensive in some cases) or the time that is often needed for collateral contacts with community agencies, school departments, and healthcare professionals.

When authorizations are approved, the time and payment allotted for the evaluation are typically so limited that psychologists are often given the draconian choice of providing an inadequate assessment or declining to take the case. This dilemma has led some psychologists to abandon the child assessment/testing role altogether.

Unfortunately, pediatricians, primary care physicians, and other medical specialists—notably, psychiatrists and neurologists—involved in the assessment and treatment of childhood mental health disorders have done little to advocate for more adequate authorizations from insurance companies for psychodiagnostic testing over the two decades which have elapsed since the advent of the managed mental healthcare era.

These trends have resulted in long waiting lists, currently extending over a year in many parts of the U.S., for children to be seen for evaluations, together with mounting “out of pocket” costs for families.

Mental health parity legislation, even if successfully implemented, may ease access to and increase reimbursement for psychological assessment. However, there are no immediate solutions for this problem.2

However, a collaborative, cost-sharing model involving parents, special education departments, and community-based psychologists can lead to the timely completion of comprehensive clinical evaluations.

In broad outline, special education departments would continue to provide assessment involving one or more of their traditional areas of expertise: intelligence and academic skills testing, parent and teacher rating scale assessment, socio-emotional screening, and speech/language evaluation.

Community-based psychologists would complete any needed, additional evaluation. This could include administration of neuropsychological tests, more in-depth socio-emotional assessment, and an evaluation of family functioning.

Fees for record reviews and attendance at psychoeducational planning meetings would be paid to the psychologist by the school department, the family, or cost-shared between the two parties.

This model is most clearly indicated for children/adolescents with complicated clinical histories and behavioral symptoms associated with significantly impaired school achievement/functioning. Many of these cases fall within the pervasive developmental disorder, post-traumatic stress disorder, and major affective/mood and/or psychotic spectrums.

For a subset of these children, there may be additional questions about risk of self-harm and/or harm to others. These types of cases pose significant challenges for parents and school staff when it comes to the completion of an affordable in-depth assessment.

I have worked successfully within this model on a number of cases in recent years. Research is needed to clarify the extent and success of this practice nationwide.