Stressing the already burdened pediatric behavioral health system

Emily Hangen said it only took a few weeks after her family began isolating in their home in Winslow, Ariz., for her to notice changes in her four children.

“There were behavioral issues, incidents of acting out, being angry, sleeping more or sleeping less depending on the child,” Hangen recalls. “We had one that just wanted to eat and one that didn’t want to eat at all—overall depression.”

While Hangen’s oldest child was receiving counseling services for issues with depression diagnosed prior to the pandemic, getting behavioral healthcare support for her other three children has been a major problem.

“It is pretty much impossible to get any professional assistance,” Hangen said. “Between the pandemic and just the lack of services available in our area, they have not been able to get any professional help.”

Hangen’s challenges in finding behavioral health services for her family reflects a problem that has been exacerbated by social distancing. The isolation has been particularly hard for many children, which has led to a surge in reported cases of youth mental health disorders and incidents of self-harm.

Stakeholders fear the true tipping point could come years after the pandemic’s end when providers begin to see the health impact of children with mental health disorders that were left undiagnosed, unmanaged and untreated.

As a result, the current environment has presented a unique opportunity for healthcare as a whole to re-examine and change how pediatric mental healthcare is delivered. Some remain hopeful that the impact of the past 12 months will inspire providers to adopt care strategies that promote prevention and address social stressors that could lead children to develop longer-term emotional issues.

Hospitals across the country have seen surges in mental health-related emergencies among young people over the past year. Dr. Steven Jewell, director of pediatric psychiatry and psychology at Akron Children’s Hospital in Ohio, said inpatient pediatric psychiatric units have remained at full capacity for the past several months. He said the majority of young people being admitted are coming from the emergency department after threatening or attempting suicide, harming themselves, or experiencing a drug overdose.

The proportion of mental-health related ED visits increased by 24% among children ages 5 to 11 and by 31% among youth ages 12 to 17 from March to October in 2020 compared with the same period in 2019, according to an analysis released last November by the Centers for Disease Control and Prevention.

“For once, it’s accurate to say that the whole world is under stress and it’s certainly impacting kids,” Jewell said.

A recent report by the not-for-profit healthcare transparency advocacy group FAIR Health found mental health claims for youth ages 13 to 18 as a percentage of all medical claims increased by nearly 20% in 2020 compared with 2019, during a period when medical claims overall decreased.

The rise in demand for behavioral health services has put further strain on a healthcare system that was already struggling for years to meet treatment needs. Many hospital inpatient psychiatric facilities have been at full capacity for months, leading to longer delays for children needing a bed in a psychiatric unit. Similar delays exist for patients looking to schedule an outpatient visit, with some providers having wait times as long as several months to see a mental health professional.

For facilities like Cincinnati Children’s Hospital Medical Center, the high volume of patients seeking behavioral health services has pushed back the average wait time to see a professional from roughly two weeks to as long as two months. In response, the hospital has adopted more of a triage model throughout the pandemic. Rachel Herbst, a clinical pediatric psychologist at Cincinnati Children’s, said the shift in their care delivery approach in response to the current demand challenges has forced the health system to skip many of the preventive approaches they normally employ, which she feared could have long-term consequences.

“They’re just going to continue to have needs, and then eventually cross that threshold into having more significant mental health needs,” Herbst said.

Experts have attributed the rise in youth mental health-related emergencies over the past 12 months to an increase in stressors brought on by the pandemic.

Factors that include a lack of social contact, economic uncertainties and fears about contracting the virus have all been attributed to heightened anxiety levels among family members. Such conditions have also led to increased rates of domestic abuse during the pandemic, which has exposed children to more trauma that can increase their likelihood of having an adverse childhood experience, or ACE.

A standard method for more than two decades for detecting children’s risk levels for developing physical and mental health concerns, the ACE score system was developed in 1997 based on an investigational study conducted by the CDC and Kaiser Permanente. ACEs have been associated with higher rates of chronic disease, risky health behaviors and depression. The more ACEs a child has, the higher their likelihood of having poorer physical and mental health.

Some feel the pandemic has had such a large impact on the mental health of children and their families that it should be considered an ACE in its own right that healthcare providers should not overlook when evaluating children for possible behavioral health issues.

Kristen Choi, an adolescent psychiatric nurse and assistant professor at the UCLA School of Nursing, said using ACE scores can be a helpful way for clinicians to identify kids in need of help. But she said many of the screening tools don’t capture all of the potential stressors a child may experience. Many screeners were not designed to address factors less related to family or household dynamics and more environmental, like the effects of racial discrimination or experiences children may have at school.

“Of course, they weren’t designed to capture pandemic stressors,” Choi said. “But we could re-design them, and maybe we should.”

Challenges in identifying certain stressors brought on by the pandemic have raised concerns among providers over how many children have fallen through cracks of the healthcare system during the past year.

Choi said screening efforts have been severely hindered by extended nationwide school closings. Schools serve as an early point of contact to identify warning signs of an emerging mental health condition in students, and help connect them to resources and supports.

Among children identified as having a mental health disorder, 70% of those who receive mental health services get them through their school, according to the School-Based Health Alliance, compared with the estimated 20% of children who receive care from a specialized mental healthcare provider.

Concerns over potential gaps in screening children for mental health issues has compelled a growing number of healthcare providers to universally screen their pediatric patients for social factors like poverty, parental unemployment and food insecurity.

“It’s one approach we use that really helps to inform us as to what’s going on with the family and then to respond to those needs,” said Melissa Buchholz, director of the HealthySteps program for the state of Colorado and a clinical psychologist at the University of Colorado School of Medicine’s Irving Harris Program in Child Development and Infant Mental Health.

Buchholz said UC Medicine conducted regular universal screenings of children for social needs prior to the pandemic in addition to routinely screening all patients for behavioral health concerns. In addition to its screening within its clinics, in March 2020, UC Medicine began making follow-up calls to patient families who had received services over the previous 12 months to check in and mitigate any fears over coming into the clinic.

While concerns remain that a sizable portion of children with mental health disorders may yet fail to get identified in spite of such efforts, experts credited universal screenings as an important tool in identifying more children with potential mental health issues.

But arguably a larger factor has been the ability of providers to improve children’s access by increasing the number of providers able to identify and assess mental health issues as well as provide some level of treatment. Many have been able to achieve this by getting more primary-care clinicians to ask patients and their families about mental health concerns.

“The way that we’re going to better identify kids who are struggling is by asking if kids are struggling,” said Meghan Walls, a pediatric psychologist and legislative policy adviser at Nemours Children’s Health System in Delaware. “It sounds really logical, but it has not always been historically how medicine has worked.”

Despite a dearth of available local resources, Hangen said her family has still been able to receive some support.

Throughout the pandemic, Hangen has participated in the HealthySteps program operated through a local community health center, North Country HealthCare in Flagstaff, Ariz. HealthySteps is a national initiative offered in 24 states that provides support to families with children up to age 3 by placing early childhood development specialists within pediatric primary-care settings, funded mostly through a combination of federal and state grants.

A program specialist has helped Hangen coordinate doctor visits for her 3-year-old son Timothy, connected her with a case worker to apply for public health insurance coverage for his medical expenses, and helped arrange play dates with other children.

Rahil Briggs, national program director for HealthySteps, said the goal is to offer the same type of comprehensive, coordinated approach to care for children’s mental health needs that most patients would expect to receive for their physical health concerns.

“If we had the same lack of follow-through when it comes to connecting to care for cancer that we do for mental health, we’d be up in arms as a society,” Briggs said.

While school health clinics and community organizations are vital partners in the effort to expand access to behavioral healthcare services, some see opportunities for healthcare organizations to create more touch points where children can get access.

“A lot of times when a kid is going in for something as simple as a school physical that may be the only time you will ever see them because children all in all are healthy,” said Dr. Howard Pratt, a pediatric psychiatrist at Community Health of South Florida, a Miami primary-care center and school-based health service provider.

Efforts to expand access to behavioral healthcare have seen increased interest in the adult patient environment over the last decade by integrating mental healthcare within primary-care settings. Yet such care delivery approaches are not as prevalent in pediatric settings, where experts say they could have the most benefit.

Dr. Lateefah Watford, chief of behavioral health for Georgia-based Southeast Permanente Medical Group at Kaiser Permanente, said the health system is in the process of expanding its behavioral health medicine specialist program to include pediatric primary care. The specialists are embedded within primary-care clinics where they help clinicians manage patients with mental health disorders or refer them to more specialized treatment.

In spite of such individual efforts, the rising need among children for mental health services has many fearful that without more robust support the country faces a tsunami of unmet needs that the health system will not recover from for years.

Whatever impact the relief funding may have— $130 billion is allocated to schools for grades K through 12—some say it will not be enough if most providers go back to operating the way they did pre-pandemic.

“We are dealing with a reckoning in terms of the need for mental health treatment in this country at all levels, and especially at the child and adolescent level,” said Dr. Stephen Mateka, clinical director of children’s behavioral health services at New Jersey-based Inspira Health Network. “Not learning from this experience would not only be devastating, it would be reprehensible.”