When the Robert Larner, M.D., College of Medicine at the University of Vermont surveyed more than 30 pediatricians and family medicine doctors around the state a few years ago about child mental health, one result was particularly notable: Over three-quarters of them reported that they had patients with “moderate to severe” mental health complexities for which “they were operating outside of their scope of practice and comfort.” The doctors wanted more education and connections to specialists to help their patients.
In response, the Larner College of Medicine created a 12-session youth mental health education series for primary care clinicians, with specialists covering such issues as eating and sleep disorders, gender identity challenges, self-injury, substance abuse, and autism.
“It’s really helped with screening, asking the right questions, and knowing what’s our next step” to make sure children get the right treatment, says pediatrician Colleen Moran, MD, who was one of the session participants.
That project is one example of how specialists and primary care clinicians are working together in new ways to confront the challenge of youth mental health, which the U.S. surgeon general recently declared a “national crisis.” The surgeon general’s advisory, released in December 2021, noted that the COVID-19 pandemic has exacerbated an ongoing rise in reports of anxiety, depression, disruptive behavior, and self-harm among youths — reflecting what pediatricians are seeing across the country.
“We're having more positive screens [for mental health issues] than I've ever experienced in my career,” says Ariana Hoet, PhD, pediatric psychologist at Nationwide Children’s Hospital in Columbus, Ohio.
But Hoet stresses that youth mental health needs reached crisis levels long before the pandemic. The surgeon general’s report backs that up, noting that before COVID-19, “an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide — and rates have increased over the past decade.”
At the same time, the country doesn’t have nearly enough child and youth mental health specialists to meet the need. “We will never have enough specialized providers,” says pediatric psychologist Rachel Herbst, PhD, integrated behavioral health lead in the Division of Behavioral Medicine and Clinical Psychology at Cincinnati Children’s Hospital Medical Center.
Instead, the goal is to expand the capacity of all children’s health providers to address mental health. The strategies focus on training primary care doctors to better recognize and address mental health ailments, expanding networks for consultations and referrals to higher levels of treatment, and integrating the work of front-line physicians and mental health specialists.
Little access to care
Imagine breaking a leg and having to wait weeks or months to receive treatment. In many places, that’s how long it takes a child or teenager to get a first appointment with a therapist. Getting admitted to a hospital for psychiatric care typically takes longer.
Such lack of access to care is a main reason that “probably no more than half of the kids who are affected by mental disorders get adequate treatment,” says John Campo, MD, a child and adolescent psychiatrist and vice president of psychiatric services at the Kennedy Krieger Institute Baltimore. “It’s probably easier to get an appointment for a young person with cancer than it is for a kid at risk for suicide.”
As a result, children and youths routinely show up in emergency rooms in the midst of mental health crises that have left them unable to function in their daily lives — sometimes even having contemplated or attempted self-harm. The typical emergency department is not equipped to treat mental health disorders, Campo notes. Most carry out a brief assessment of the patient, work with them and their family to ensure their immediate safety, and guide them to specialized mental health care such as psychiatric hospitalization or outpatient services — care that takes weeks or months to begin.
The rise in youth mental health cases in emergency rooms has driven health systems toward a more upstream approach: helping primary care doctors assess and address mental health issues before they reach emergency levels. “This [mental health] is part of your health care, so it belongs in your medical home,” Herbst says.
However, many child and family doctors feel that they don’t have the knowledge to adequately treat a wide range of child mental health disorders and have a hard time finding help, as the Larner College of Medicine survey and others have shown. The Annals of Family Medicine reported last month that more than 85% of 1,401 group practices caring for children said they “found it difficult to obtain pediatric behavioral health services,” including advice about medication, psychotherapy, and family counseling.
“The demand for getting help to manage these symptoms is increasing,” says Benjamin Albrecht, DO, a pediatric psychiatrist at Nationwide Children’s.
The results of the Vermont survey prompted Larner College of Medicine’s Office of Primary Care to add children’s mental health to its continuing education series, Project ECHO (Extension for Community Healthcare Outcomes), says Michael Hoffnung, DO, assistant professor of psychiatry and course director for the children’s series. Created in collaboration with the Department of Psychiatry and the Vermont Department of Health, the series brings teams of interdisciplinary specialists together with primary care clinicians to learn about patient care issues. (The Project ECHO model is used worldwide for medicine, education, and civics.)
“It really helped to see that other clinicians are seeing the same things [mental health ailments]” and to learn the latest evidence-based practices from mental health experts, Moran says. Reviewing cases from other primary care providers was particularly helpful — not only to treat specific patients but also to learn how to treat others.
“We’d bring a specific case to the group and say, ‘This one’s got me stumped. I’ve tried X and Y, but we’re still stuck,’” she recalls. “We would sort of ‘think tank’ around what the options are” for counseling, medication, and specialty care.
The goal of the training, Hoffnung says, is to empower primary care providers and care teams to better recognize and assess ailments; improve their treatment, especially for mild and moderate cases; and more easily access outside resources, such as psychiatric specialists for consultations or movement into specialized care.
At Cincinnati Children’s, which has also provided Project ECHO training on children’s mental health, the participants reported an increased ability to care for their patients’ mental health ailments, especially depression and anxiety, says Jessica McClure, PsyD, medical director of behavioral health.
“The number of referrals that have to go to specialists decreased,” she adds. “They can manage more cases within their own practices.”
Consulting and integrating
Another benefit for physicians who go through such training is that it builds their personal networks of specialists for consultations and moving patients to high-end care. Some health systems have created formal networks that all doctors can use.
In Texas, pediatricians and primary care providers get free child and adolescent behavioral health consultations through the statewide Child Psychiatry Access Network (CPAN). Doctors contact the network hub in their region to ask about mental health assessments, symptoms, and medications and get referred to mental health providers, according to Deborah Cohen, PhD, MSW, assistant professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas at Austin Dell Medical School. Cohen reports that the CPAN hub in central Texas, operated by Dell Children’s Medical Center and covering 13 counties, fielded 1,670 calls from doctors over the past three fiscal years.
In Ohio, Nationwide Children’s offers several child mental health services for physician practitioners, including a hotline for urgent consultations, virtual 15-minute sessions with psychiatrists to learn more about specific mental health issues, and Project ECHO sessions for deeper education.
“We want to make sure they’ve got the tools necessary to provide care,” says Albrecht of Nationwide Children’s. “You can’t address the whole child unless you bring their emotional, behavioral, and cognitive well-being into the picture.”
To better address those issues holistically, some health systems have adopted integrated behavioral health (IBH) strategies, which create structures — both systematic and physical — where providers such as pediatricians, mental health specialists, nurses, and social workers confer to provide an array of medical and psychiatric services, including assessing and treating children for behavioral health issues.
“Integrated behavioral health allows us to catch kids earlier” as they display initial symptoms of behavioral and mental disorders, allowing doctors to provide the right care sooner, says McClure at Cincinnati Children’s.
Cincinnati Children’s is building a five-story mental health facility for children and youths that will be staffed by doctors, nurses, and therapists with a wide array of specialties to treat the physical and mental needs of both outpatients and inpatients. The hospital said the facility will feature dedicated spaces for group, speech, occupational, and recreational therapy, as well as expanded services for patients with neurodevelopment disorders.
The primary care clinics run by Nationwide Children’s each have a social worker who is trained in suicide screening and prevention, and the hospital system is working to place a psychologist at each clinic as well, according to Hoet.
Aside from providing more holistic care, the IBH approach helps clinicians in all areas of practice learn from each other.
For example, to foster cross-disciplinary learning, Saint Louis University School of Medicine launched a fellowship last year to train professionals of various disciplines on working with children, adolescents, and transitional-age youths from marginalized communities who have complex behavioral health needs. The fellows include graduate students specializing in social work, family therapy, and clinical psychology, as well as three psychiatry residents, says Katie Heiden-Rootes, PhD, an associate professor in medical family therapy at the school and the principal investigator on the project.
Although these efforts require investments of time and money, mental health experts believe that they will save money in the long run through more effective and efficient care.
“If we can identify a 5-year-old with emerging anxiety, we can probably treat that in three to four visits,” McClure says. “If they don't get identified and treated until they’re a teenager, that is now a chronic health issue.”
Heading off that cycle requires more assessment and treatment on the front lines. In Vermont, Moran refers to pediatricians, family medicine doctors, and mental health providers as the “boots on the ground”: “We need more boots on the ground. But in the meantime, we need to train the boots that are already on the ground.”