The state of children’s mental health was already a concern before the COVID-19 pandemic. Since 2020, many hospitals and emergency departments across the country have reported a sharp uptick in demand for behavioral health services.
In response to this crisis, children’s hospitals are redoubling efforts to tackle these issues and putting renewed emphasis on leveraging community partnerships to increase access to quality mental and behavioral medical care, according to a panel of experts who spoke during a recent U.S. News & World Report webinar.
Given the great demand and a relative shortage of clinical staff to address the needs, “we’re 10 years behind the eight-ball here already, and the pandemic only laid bare some of those disparities in care, access and care quality,” said Dr. Ron-Li Liaw, who serves as Mental Health in-Chief at Children’s Hospital Colorado.
“We’re really thinking about mental health at every single table and every single key decision,” she said, “whether it’s from the policy or the primary [care] integration front, or in our emergency departments.”
In Washington state, for example, even while the severity of patients’ mental illnesses has increased, appropriate treatment options have decreased, said Dr. Alysha Thompson, clinical director and attending psychologist on the Psychiatry and Behavioral Medicine Unit at Seattle Children’s. “A third of the residential treatment beds have closed in the past three years, both for adults and for adolescents,” she said.
Thompson said the pandemic harmed the mental health of children far more than it did among adults. “For a sixth grader or for a high schooler who is missing these very momentous years of their development, I don’t think that we can say enough what that can look like in terms of impacting their social skills, their ability to interact with folks, and also the grief of loss of those years,” she said. The pandemic’s impact on children’s mental health will persist “long after we have addressed the spread of the virus.”
To help, in north Texas, “we are training our community pediatricians in recognizing and identifying mental health issues and also in treating mild to moderate issues, with the idea being that we are going to expand that access to care and prevent kids from getting to a more severe state where they would show up in the emergency room or the inpatient unit,” said Dr. Sabrina Browne, a child psychiatrist and assistant professor of psychiatry at the University of Texas Southwestern Medical Center. Browne leads the Children’s Health Behavioral Health Integration and Guidance Initiative. “We really are trying to fill that gap to, one, empower them to start that treatment, so a kid’s not sitting on a waitlist for six months, and two, creating a community of primary care providers,” she said.
Browne added that Children’s Health also uses a state-funded program to go into schools and some short-term therapy and psychiatric services until more long-term options are available.
Dr. Keith J. Loud, chair of the Department of Pediatrics at the Geisel School of Medicine at Dartmouth and Physician-in-Chief of Dartmouth Health Children’s, talked about the challenges faced in more rural locations like in New Hampshire, including the potentially long drives to larger cities. That area has also been hit hard by the opioid epidemic. To better serve these more remote communities, his organization piloted telehealth visits in the early 2000s. “We have a network of 10 primary care medical homes that we own,” he added, into which they have been embedding behavioral health clinicians in a collaborative care model.
For roughly 18 months, Children’s Hospital Colorado has been building a coordinated system of child and family mental health care across the state “to ensure equitable access to high quality care and prevention services,” Liaw said. State legislation also created the Colorado Pediatric Psychiatry Consultation and Access Program to support primary care providers in identifying and treating mild to moderate behavioral health conditions in children in primary care practices or school-based health centers.
Seattle Children’s has instituted a “daily huddle for our entire service line,” Thompson said, including all the hospital’s mental health-oriented programs. Though fairly short, those meetings have allowed health care workers across the disciplines to connect and collaborate on cases if need be.
Liaw talked about a new partnership with a school district in the city of Aurora, where, over the last decade, some 2,000 inpatient, residential beds have been lost – a “dramatic” loss, she said. As a result, providers have been forced to send children out of the district and even the state for proper mental health care. The district successfully opted to raise a bond fund, allowing the town to build both a new mental health building and school.
In Texas, Browne said, “every region has its own needs and its own community. And so here in the state, we’ve divided it up into different institutions where the different state medical schools are going into their own local communities. On a very practical level, we offer their services through telehealth so that we can get into all the schools. It is a much easier way for kids to get connected when parents don’t have to pull them out of school and don’t have to take time off of work.”
Addressing workforce issues is also on the front burner for the panelists.
It begins with entry-level positions, Liaw said, particularly “looking at folks who have either a GED or graduated from high school, who have lived experience in mental health navigating those challenges themselves or in their communities or in their families” and providing them health system-funded opportunities to pursue further education or certifications.
She added that there are also fellowship programs and an unlicensed master’s clinician pathway. Part of that includes “thinking about the diversity of the communities that we’re serving, and that we are really drawing from the talent in those communities for folks who are looking for meaningful career and economic stability.”
In a rural environment, Loud recognizes that the available workforce may always be wanting, so investing in novel technology is key. His organization’s health care incubator funds innovative projects, with hopes of some coming online in the next year.
Still, better mental health care calls for better pay for those on the front lines, the panelists agree. That necessitates stronger state and national advocacy, Thompson said. “Otherwise, we’re not going to be able to continue to pay people what we need to be paying them.”
Addressing the need for early intervention, Liaw noted that there is often up to a 10-year delay from a first symptom or warning sign to actually accessing care. “There’s a huge return on investment for every dollar, every intervention, every support, every touch for a family early in life that we would see dividends on in functioning and quality of life and relationships and educational attainment, if we would think, as a society, about the long game for this generation.”
Given that nearly two-thirds of adults report that they’ve experienced at least one type of adverse childhood experience, “we should make an assumption that anybody that we interact with has experienced something adverse in their life,” Thompson said. “Most have more than one, sometimes five-plus adverse childhood experiences that they’ve lived through.”
She continued: “The experience of racism is trauma. The experience of homophobia is trauma. Thinking about what youth are experiencing because of who they are is really, really important to make sure that we can then provide them with the resources they need, and then also do work to make sure that they don’t have to have those experiences.”
On a positive note, the panelists acknowledged the rise in celebrities and other leaders speaking about their own mental health challenges. Browne expressed encouragement from the “shift in the attitude towards mental health that we’re seeing on the societal scale.” On the other hand, younger generations risk misinformation and over-diagnosing due to content on platforms like TikTok, so those in the medical community must stay on top of educating and contextualizing the information being spread, she added.
Looking ahead, integrated behavioral health programs will become more common, Browne said. “Instead of just having the behavior health care manager who’s getting the referrals and working with families, we’re integrating it more so that there’s a psychiatrist, there’s a pediatrician … I think that we’re going to see a lot of that in the future.”
In Colorado, suicide is the leading cause of death for kids beginning at the age of 10, Liaw said, and rates of suicide have climbed dramatically in recent years. Among the ways that Children’s Hopsital Colorado is addressing suicide are “actually using data science and artificial intelligence for clinical decision support, predicting risk and resiliency factors in different populations, looking across disparities in different regions and different underrepresented groups, underserved groups.”
Despite all these challenges, “I feel very hopeful about where we’re heading in mental health,” Liaw concluded. “We are all struggling with the same challenges. But there’s some innovative solutions out there that we can steal shamelessly from each other, build upon, borrow.”