Deseray Burtenshaw's heart sank last month when she received a letter that could change the life of her 4-year-old son.
The letter from Optum Idaho, the state's contracted administrator of Medicaid-reimbursed outpatient behavioral health services, said Burtenshaw no longer will be reimbursed for psycho-social rehabilitation to treat her son's ADHD - attention deficit hyperactivity disorder - and oppositional defiant disorder.
Psycho-social rehabilitation is a treatment that involves trained professionals taking patients out into society and teaching them the skills they need to cope with their disturbances.
Elijah has been receiving psycho-social rehabilitation services at the Reach Beyond mental health clinic twice a week for nearly a year after behavior problems led to the boy's repeated dismissals from preschool. His last session is scheduled for July 17.
Reach Beyond program director Mallori Warren said the clinic has seen more and more clients lose their psycho-social rehabilitation services since Optum Idaho was contracted in September.
Idaho Psychiatric Rehabilitation Association chairwoman Jodi Smith said Optum Idaho has been cutting psycho-social rehabilitation hours for children with ADHD and other behavioral issues across the state.
Idaho Department of Health and Welfare spokesman Tom Shanahan said 9,203 children received psycho-social rehabilitation in fiscal year 2013.
While the number of children removed from psycho-social rehabilitation was not readily available, Smith estimated about half have lost Medicaid coverage for the treatment.
Burtenshaw, a single mother of three, is worried she won't have the resources or knowledge to deal with Elijah's behavior on her own.
"It's absolutely heartbreaking," Warren said. "The kids and their parents feel cheated."
THE ROAD TO WELLNESS
Elijah has a smile as big as his Mohawk haircut. When he went for his semiweekly visit Monday with Brent Packer, his psycho-social rehabilitation worker, he had no idea it would be one of his last.
Elijah greeted Packer with a big hug at the Reach Beyond clinic before they went downstairs to work on his human interaction skills.
"When I first started working with Elijah, he was getting into a lot of fights at school and causing trouble," Packer said. "He's made a lot of improvements since then, but we still have a ways to go."
Regression is one of the dangers of removing a child from psycho-social rehabilitation services before they're ready, Warren said.
"We don't want them to have to rely on these services their entire lives," Warren said. "The goal is to teach them the skills they need and slowly reduce the frequency of visits until they graduate (from the program). If they stop before graduation, it's going to be a lot harder for them to get back on track."
Elijah needs at least six more months of psycho-social rehabilitation, he said. But in the letter Burtenshaw received, Optum Idaho said Elijah had six weeks left.
At issue is a dispute about the effectiveness of psycho-social rehabilitation therapy. Optum Idaho does not support it as an "effective treatment" for ADHD.
"Before Optum, community-based rehabilitation services were authorized as an approved service for children with ADHD despite limited medical evidence to show that community-based rehabilitation services were effective in treating children with ADHD," Optum spokesman Brad Lotterman said in an email. "The most widely accepted evidence-based practice for ADHD in children is behavior therapy."
Conversely, the National Resource Center on ADHD, a "national clearinghouse for the latest evidence-based information on ADHD" funded by the U.S. Centers for Disease Control and Prevention, describes psycho-social treatment as "a critical part of treatment for ADHD in children and adolescents." The center's website says treating ADHD in children often involves a medical, educational and behavioral approach.
Shanahan, the Health and Welfare spokesman, said behavioral therapy - a one-on-one interaction with a therapist - "seems more appropriate for a child with ADHD."
Smith, of the Idaho Psychiatric Rehabilitation Association, said the lack of empirical data for the effectiveness of psycho-social rehabilitation is because the approach is so new.
"We only started offering (psycho-social rehabilitation) in the '90s," said Smith, a counselor who co-owns a mental-health business in Coeur d'Alene. "There was no monitoring at first, and providers were flying by the seat of their pants."
The early stages of psycho-social rehabilitation gave it a reputation of a "baby-sitting" service, Smith said. As the treatment progressed, she said, stricter guidelines were set and psycho-social rehabilitation workers had to get certified in many states, including Idaho.
Psycho-social rehabilitation is effective, Smith said, because the workforce has improved over time. "Psycho-social rehabilitation is a skill-building service that engages the child and the family," she said. "It's a very hands-on approach to replacing maladaptive behaviors with adaptive behaviors. When it's applied appropriately it really does work."
Kelly Keele, president of Children's Supportive Services, a community-based behavioral and mental health clinic, said psycho-social rehabilitation succeeds.
"When we first started close to 90 percent of the children that we saw had been hospitalized," Keele said. "When we were providing (psycho-social rehabilitation), we had less than 10 percent hospitalized. If we pull out the community support, we're going to see more kids hospitalized, mixed up in the judicial system and not being able to participate in school and in the community."
'CUT, CUT, CUT'
While Smith is disappointed in Optum Idaho's decision, she doesn't think the company is "out to get" mental health providers.
"I think they are just trying to clean up a mess," Smith said. "However, there is more fact checking to be done and more historical perspectives to be considered in order to make better decisions. The blanket approach of 'cut, cut, cut' doesn't help anyone."
As for Burtenshaw, she's worried that cutting Elijah's psycho-social rehabilitation time will harm him later in life.
"I'm worried that kids won't get the help they need and learn the skills they need to learn," she said. "That could lead to them coping with things themselves and turning to drugs and alcohol."
The Idaho Statesman contributed.