“Children are not little adults,” I said at a recent meeting. “They go home to families, not their own apartments. They go to school; they are not employed. And when they have mental health problems, it’s episodic, not chronic. “
I haven’t had to say that children are not little adults for quite some time, but I find I am saying it a lot lately. When I first began this work, there was a wonderful paper written by Trina Osher (who was then the policy director at the Federation of Families for Children’s Mental Health) called “Why Children Are Not Little Adults.” (Click here to read it.) It was targeted to managed care companies and I quoted it a lot. We were seeing the beginning of a shift to insurance (including Medicaid) as a primary funder and designer of treatment and services for children and teens with behavioral health needs, a shift that continues to this day.
It was important that those creating and approving services understood that what worked for adults and was appropriate for them might not work for children. Children, Trina Osher wrote, “continuously require the support of their parents, siblings and other family members.” She emphasized that there must be respect for the family’s culture and beliefs. Children have a need not just for food, clothing and shelter, but for protection, which makes them especially vulnerable. Their mental health and physical health needs are intertwined.
Many of these ideas became familiar to others – providers, funders, state agency staff and educators. At meetings, I often heard others articulate them so I didn’t have to. Now, fast forward to today.
Today, we are having discussions about health homes and integrated care. We’ve expanded our understanding to recognize that children and youth who have experienced trauma or have co-occurring medical or substance use needs should be included when talking about children with mental health needs. Yet, I find I am reminding people once again that children are not little adults. Why is that, exactly?
It’s easier to design new systems (such as integrated care) for adults and retrofit children and youth into them. It’s more efficient to create priorities for the mental health system overall and say children are included as SAMHSA has, instead of making children, youth and families a priority all its own. It’s less trouble to pay for traditional treatment that works (at least sometimes) for adults, such as inpatient and outpatient and call it a day as many private insurers do, instead of reimbursing treatments that work better for children.
However, there is one place where I still don’t have to remind folks that children are not little adults. That is any table where pediatricians sit. Like parents, they see children change and grow each year. Like parents, they encounter the many systems (child welfare, education, juvenile justice, child care) that they need to communicate to and coordinate with.
In a 2010 policy statement on family-centered medical homes, several well-known pediatricians outlined the issues that are unique to children and families when designing and providing care. They contrasted them with the needs of adults, where the focus is on maintaining health, making decisions for oneself and moving toward recovery.
The pediatricians call the unique issues for children “The Five D’s. “ Here’s a quick recap:
1. Developmental changes. Children grow and change and their ability to understand, self-manage and participate grows too. Every parent knows this well. Treatment and services should maximize this amazing potential rather than focus on regaining lost skills (as with adults).
2. Dependency. Children are dependent on parents and other adults (they don’t go home to their own apartments, remember?) which calls for a collaboration with their family. Coordination with early childcare and schools is essential. This dependency decreases as children grow older and their autonomy increases, which is another developmental change.
3. Differential epidemiology. Simply put, pediatricians don’t see many chronic health conditions such as high blood pressure, diabetes and heart disease in children while they do see a fair amount of obesity, mental health conditions and asthma. Big need here for prevention and care coordination, which are not emphasized in the adult world.
4. Demographic patterns. While poverty in elderly populations has dropped dramatically in the last 40 years, child poverty is little changed. As a group, children are also more diverse than adults (Horn, Beal, 2004). Poverty and diversity contribute to many children being vulnerable to poor health and poor quality of care.
5. Dollars. While overall costs for health care for children are small compared for adults, there are “50 different ways” to pay for it. The good news is an investment in children can produce substantial savings over a child’s lifetime.
The bottom line is that we are once again seeing the health care system shift. When “Why Children Are Not Little Adults” was first published, we were seeing the growth of managed care in both private and public (Medicaid) insurance. We know that the treatments and services are that available to children, youth and families are often determined by what funders pay for. Today’s discussions are also groundbreaking. New approaches to care are being designed and funded including medical/health homes, integrated care and the possibility of expanding mental health care under federal mental health parity.
To make that happen, we need parents and pediatricians at the table. I know they will talk about what works for children and youth and why it’s important to include families. I know they will talk about families from diverse cultures. I know they will not confuse the needs of children and youth with those of adults. And they shouldn’t. We simply can’t afford to.