Q&A: Pediatricians on front line of mental health crisis

Key takeaways:

• Pediatricians are on the front line of the pediatric mental health crisis.
• There are numerous resources available to help them respond to the crisis.

May is Mental Health Awareness Month in the United States.

With the country in the midst of a national emergency in pediatric mental health, we spoke with Marian Earls, MD, chair of the AAP’s council on healthy mental and emotional development, about the crisis and the resources available to pediatricians caring for patients with mental health issues.

Earls is a developmental and behavioral pediatrician and medical director of the North Carolina-based nonprofit pediatric practice Guilford Child Health.

Healio: What are the major mental health issues that pediatricians are seeing in practice?

Earls: Pediatricians realize that there's a huge mental health crisis in the country. Pediatricians and other primary care clinicians are on the front line, seeing families that come in with distress and children with functional issues at home and school. These concerns are happening across the whole range of ages, from infant/toddler through adolescence. Families have had so much adversity as a result of the COVID-19 pandemic — loss of child care and loss of jobs, loss of socialization, etc. Families have been under a tremendous amount of stress.

What pediatricians have been seeing is that even some of the youngest kids who are coming in to see them are showing functional issues. And then, of course, we know about the crisis of suicidality, particularly the increase for adolescent females. We have recently heard about the Youth Risk Behavior Surveillance System survey, where so many kids acknowledged that they were experiencing loneliness and emptiness. Pediatricians have seen increased rates of anxiety in their patients, even among younger school-aged children. There is a heightened awareness of having to be ready to address these issues, to know what resources there are in their community and to know how to engage with families to plan care. I have heard from pediatricians in Zoom meetings and other forums that they are feeling the push to manage depression and anxiety on their own. They're being asked to routinely use validated screening tools to assess socioemotional health for all ages and, in addition, to screen for depression and suicidality in the adolescent years.

Healio: What would you say are the major resources available to pediatricians on this topic?

Earls: The AAP has numerous resources for pediatricians, including a Mental Health Toolkit [Editor’s note: See link below], strategies for promoting healthy mental and emotional development at all ages, guidance regarding validated screening tools and having conversations about screening with patients and families, guidance for assessing symptoms and identifying a diagnosis if present, guidance for interventions and treatment and for comanagement with mental health professionals.

Pediatricians can work on incorporating mental health care by participating in Project ECHO [link below] and online courses and learning collaboratives. Although many of these resources have been available for some time, there is an urgency created by the crisis in mental health to support pediatricians in using these resources for their practices. The AAP also has, and is developing, resources to give practices technical assistance in integrating mental health professionals as part of the practice clinical team.

Another outstanding resource are the Child Psychiatry Access Programs [link below]. In the last several years, the Health Resources and Services Administration has funded new access programs with Pediatric Mental Health Care Access grants so that these now exist in most states (46 states and 49 programs). With a child psychiatry access project (CPAP) program, primary care clinicians can, in real time, call in and talk to a psychiatrist or a licensed clinician/therapist, or they can talk to a care coordinator to find resources for families. The child psychiatry access programs are an outstanding resource. Some of the most well-developed ones are in Massachusetts, Washington State and Michigan. This expands the capacity of child and adolescent psychiatrists and allows pediatricians who are in smaller, rural or under-resourced communities to consult with a mental health professional and not have the family required to travel distances and wait for availability of referral.

The new 988 crisis line is another promising development for pediatricians who identify a crisis or suicidal risk to access immediate services for the patient and family.

Healio: Are any advances coming in screening techniques, specifically for depression, suicide risk and anxiety in office settings?

Earls: Bright Futures actually recommends routine promotion and prevention approaches. Starting in infancy, it is recommended that we use a screen that's age appropriate and validated to assess social emotional development, whether that child is aged 1 year, 5 years, 10 years or 18 years. The recommendation is to promote strengths and protective factors and to screen and discuss routinely, whenever someone comes in for a well visit instead of waiting until a patient presents with problems.

In pediatric care, the advantage is the longitudinal relationship with the child and family. There are many resources to assist practices to choose a validated screening tool based on the child's age. It is not just about doing the screen. Most importantly, it is also knowing how to engage with the patient and the family in discussion — whether the screen shows concern or not — and to make a plan together. If there is a wait time for a child or adolescent who needs a referral, there are supports and follow-up approaches to be implemented in the interim while waiting for that referral. In addition, it is recommended that we routinely screen for depression starting at age 12 years. There is now — given the data that suicide is the second leading cause of death in 10- to 24-year-olds — a recommendation to screen to assess for suicidality routinely, not just with somebody who has symptoms, starting at age 12 years. This is a relatively newer recommendation. There are screening tools that can be implemented in primary care practice. It is also recommended that practices routinely screen the mother/caregiver at infant visits for perinatal depression. Perinatal depression not only impacts the caregiver, but it also impacts the child and the family.

Screening, therefore, is a part of promotion and prevention. But pediatricians will also have patients come in who are experiencing symptoms, at home and/or at child care or school. This means that the pediatrician needs to know the functional symptoms that are “red flags” for a mental health issue and how to assess further for a possible diagnosis. The AAP has a mental health toolkit for practices to ready their practice, to implement promotion and prevention processes, to use a symptoms-based approach to assess for a diagnosis and develop a plan of care with the family and to comanage with mental health specialists as needed. The AAP recommends that pediatricians are able to assess and to manage mild to moderate depression, anxiety, ADHD and substance use problems.

Healio: In your opinion, are there enough pediatric mental health clinicians currently working?

Earls: There are shortages of pediatric mental health clinicians, including child and adolescent psychiatrists, developmental behavioral pediatricians and licensed mental health professionals who serve children and adolescents, particularly very young children. In addition, there are shortages of services for those with more critical needs for mental health hospital beds, step down units and crisis services.

It is very difficult in many communities to find therapists who have been trained in evidence-based treatments for very young children, and to find therapists who treat older children and adolescents. However, we know that therapy is the first line of defense for most of the things we identify, even when medication is indicated.

There has been a call for many years to expand the workforce. It is a complex issue that also involves policies and payment. Nationally, it is often the case that payment for mental health care is much less for care delivered to children and adolescents than to adults. There have been calls for payment reform that payment for children's mental health ought to be comparable with payments for adult mental health. The AAP, in conjunction with national partners, has published mental health principles to address of these things to support children's mental health.

I am the chair of the new AAP council developed in response to the mental health crisis — the council on healthy mental and emotional development. Our role is to advise the Academy on Mental Health priorities for action. The AAP is committed to ensure equity to address the structural racism that has resulted in the health disparities that are very real in this country. Not only do we have shortages and policy and payment issues, there are disparities in access to mental health care and mental health outcomes for Black, Indigenous and people of color and marginalized populations.

It is essential for the public, families and children, policymakers and educators to understand healthy mental and emotional development. There needs to be policy and payment structures that ensure an adequate workforce and availability of services.

References:

AAP. Project ECHO. https://www.aap.org/projectecho.

AAP. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. https://publications.aap.org/toolkits/pages/mental-health-toolkit.

National Network of Child Psychiatry Access Programs. Integrating physical and behavioral health care for every child. https://www.nncpap.org/.