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Attending to the Pediatric Mental Healthcare Gaps: Addressing Existing Inequities

Authors: Hansa Bhargava, MD; Christine M. Crawford, MD, MPHFaculty and Disclosures


Activity Transcript

Hansa Bhargava, MD: Hello. I'm Hansa Bhargava, Chief Medical Officer of Medscape Education. Welcome to this program. It's my pleasure to welcome Dr Christine Crawford, Associate Medical Director from NAMI, the National Alliance on Mental Illness. Today, we'll be speaking about “Attending to the Pediatric Mental Healthcare Gaps: Addressing Existing Inequities”. Dr Crawford, thank you so much for being here. We'd love to hear a little bit about you.

Christine M. Crawford, MD, MPH: Great, thank you so much for having me. My role is Child and Adolescent Psychiatrist at Boston Medical Center. In addition to my clinical role, I am the Associate Medical Director for the National Alliance on Mental Illness, also known as NAMI, which is the largest grassroots organization dedicated to improving the lives of individuals living with a mental illness, as well as providing support and resources for their loved ones. I'm really looking forward to this discussion with you so that we can talk a little bit more about pediatric mental health, which is such an important topic, as we all already know.

Dr Bhargava: Absolutely, Christine. I think that, especially right now, it's more important than ever. So glad to be talking to you about this. Let's get into it. Let's just start with the first question. Mental illness is more common than many of us think. It's often stigmatized, and people don't really talk about it. Can you give us an idea of its impact?

Dr Crawford: Absolutely. I think what's really important for people to know is that mental illness, and the symptoms of mental illness, can present at a very young age. It's often overlooked and not adequately addressed. What we know to be true is that 50% of all cases of mental illness, those symptoms emerge prior to the age of 14. 75% of those symptoms are present by the age of 24. Having mental health symptoms, especially when they present at a young age, can have an impact on a young person's ability to function. It can really alter their trajectory and where it is they end up when they become adults. We know that about 50% of students by the age of 14, or even older, who have a mental illness, actually drop out of school. That just goes to show that having these signs and symptoms of a mental illness can really impact your ability to learn, which is so crucial for our young people.

In addition to that, having ongoing symptoms of mental illness at a young age, can make it such that people engage in more problematic or disruptive behaviors that can be really having a negative impact on that person's life. We know that 70% of youth who are in state and local juvenile justice systems have a mental illness. It's really significant and important for us to have these conversations about mental illness, especially as it pertains to young people, so we can ensure that our young people stay on a healthy and positive trajectory so that they can become productive and happy adults later on down the road.

Dr Bhargava: Those are astounding numbers, Christine. Just going back to the 70% of youth in state and local juvenile justice systems have a mental health, just going backwards, half of those probably have symptoms by the age of 14. That means a third of people who are in these juvenile justice systems could be prevented by looking at that. Am I correct?

Dr Crawford: That's absolutely right. That's why it's just so important for adults in children's lives to be able to recognize these symptoms so that they're not being identified when they're caught up within the legal system, which we know can certainly play a negative role in any opportunities that that child could have down the road.

Dr Bhargava: Yeah, absolutely. What about suicide? Can we talk a little bit about that? We know, as pediatricians, that that is definitely on the rise. It's alarming.

Dr Crawford: It really is alarming because when we look at the data, suicide is the second-leading cause of death among people between the ages of 10 to 34. I just want that age range to sit with you for a little bit because we're talking about 10-year-olds. We're talking about very young children who are having these thoughts, and unfortunately, are losing their lives to suicide. Three million adolescents, between the ages of 12 to 17, actually have had serious thoughts of suicide. Nearly 4 million young adults have had serious thoughts of suicide.

Now, this is during a time, a very critical time in individual's lives. These are impactful years. The fact that so many people are experiencing these intense and serious thoughts, it's incredibly alarming. We know that when we're looking at the numbers of people who actually die by suicide, about 90% of those individuals had an actual mental health condition. What has been concerning to me, as well as other mental health providers, is that we're continually seeing a trend in which people are presenting to the emergency room in a state of crisis because they're having such serious thoughts such as suicide. We've actually seen a 31% increase in mental health-related emergency room visits. What we hope is that people are able to get the help and supports that they need out in the community to prevent a crisis from occurring, to prevent having to seek out mental health supports in the emergency room setting, but more than a third, unfortunately, are presenting in an acute state of crisis to the emergency room.

One group that I just want to highlight is that young people who are part of the LGBTI+ group, lesbian, gay and bisexual youth, they are 4 times more likely to attempt suicide when compared to straight youth. We know that that is a particularly vulnerable group that warrants attention in terms of specific interventions that could be done to prevent this from occurring. When we're thinking about mental health and some of the conditions that can contribute to some of these alarming statistics, it's important to note that there are a variety of mental health conditions that young people can experience that can result in significant functional impairment and can provide a lot of distress for that young person.

Looking at depression, for example, nearly 2 million kids between the ages of 3 to 17 have symptoms of depression. When we're thinking about anxiety, which is a very common mental health condition among young people, about 4.5 million children between 3 to 17 have anxiety. ADHD, a condition that is commonly discussed within this age group, over 6 million people under the age of 18 have ADHD. We're looking at really, really young kids too, talking from ages 2 to 8, and about 17% of kids within that age group, within that age range, actually have a mental health condition.

These numbers demonstrate that mental health symptoms can present very young. They can result in significant distress. We're seeing that play out with the growing rates of suicide, suicide attempts, as well as people presenting to the emergency room in the state of crisis.

Dr Bhargava: Gosh, Christine, it's such a crisis, isn't it?

Dr Crawford: Mm-hmm.

Dr Bhargava: I mean, it just is. I just want to ask you these numbers and thank you so much for this data. Are these numbers before the pandemic or during the pandemic?

Dr Crawford: Yeah, that's an important thing to note. A lot of these numbers are before the pandemic and may include some initial data from 2020. But what is alarming is that we've seen an increase in symptoms of depression and anxiety over the course of the pandemic, especially among young children between the ages of 11.

When we looked at the rates of depression and anxiety within this age group, and when we compared it to data that was obtained during the pandemic, we actually saw a 13% increase in the rates of anxiety and depression among children between the ages of 5 to 11. When we look at different rating scales that are often administered within a primary care setting that allows for pediatricians and other providers to assess mental health symptoms, and that's the PSC-17 is the most common used rating scale to assess for some of those symptoms, we saw that there was an increase in people reporting, kids reporting, that they were having some of the internalizing symptoms that we see in the form of anxiety and depression. They rated higher with regards to the internalizing symptom score.

This is due to a lot of different factors. COVID was tough for everyone, but unfortunately, given all of the quick pivots and changes that needed to occur during the pandemic, especially when it came to virtual learning, we saw that virtual learning was actually associated with worse mental health outcomes, based on a COVID experience survey that was released in the fall of 2020. Caregivers actually reported that their children who were enrolled in virtual school, had worse mental health symptoms and outcomes, about 25% of those caregivers who had kids in virtual learning reported worse mental health symptoms when compared to caregivers who had children who were at in-person school. That was around 16% of those having worsening mental health symptoms during the course of the pandemic.

You can imagine if you're experiencing all of these symptoms of anxiety and depression and worries about the pandemic, is that it could result in some difficult behaviors, such as not being able to complete your schoolwork in a timely fashion, and also spending a lot of time behind screens, whether that's the phone, your iPad or the TV. We've seen an increase in screen time. Just ongoing media exposure to the pandemic information, increased social media use, all of these things kind of factored into some of the symptoms that we saw. In addition to having worries and fears about getting the virus, as well as worries and fears about your family members getting sick from the virus. These were all difficult things for kids that have to manage.

If caregivers are overwhelmed and stressed and may even have symptoms of depression themselves and they're not able to be fully present and engaged for their child and provide the support that they need, that could also contribute to some worsening mental health symptoms within kids if their caregivers are also struggling with their own mental health issues.

Dr Bhargava: I mean, it was just a really difficult time for the kids. Christine, I will just point out that for kids who had disabilities, or kids who had ADHD, for example, the learning virtually was even more challenging. Of course, it was much more challenging for parents who were relying on school support systems for some of those issues. I mean, the kids have really, really suffered. I’m going to turn to another topic here. That's marginalized populations. I really want to talk a little bit about that and just be mindful of our time here, but I mean, if you could just at least highlight a few issues around that. I think that that's very important as well.

Dr Crawford: Thinking about marginalized populations and some of the risk factors that we see that can contribute to worsened mental health outcomes within those groups, is that unfortunately with our marginalized populations, we do see poverty and food insecurity. We do know that kids who are living under such conditions, can certainly be at increased risk for ADHD, aggression and anxiety, as well as suicide attempts. When we're looking at poverty and food insecurity, unfortunately, we see that tends to be more common among Hispanics and non-Hispanic Black households. It's a particular area of concern.

Also, things such as community violence, racism and discrimination, and lack of mental health treatment for people who are part of Black and Brown communities because that means that they have ongoing mental health issues that aren't being addressed. We see that there's kind of decreased rates of mental health care utilization that is certainly concerning. That certainly puts kids at increased risk, if their loved ones aren't getting the help that they need, and they, themselves, aren't getting the help that they need, especially if they do have a diagnosable mental health condition.

Dr Bhargava: Yeah, absolutely. What do you think are the long-term effects of these experiences? I mean, we have heard about the ACEs and toxic stress. Can you talk to that a little bit?

Dr Crawford: Yeah, in terms of the long-term effects of what is happening, we know that it's been an incredible stressor and a lot of kids have gone through significant adversity as a result of this pandemic. Looking at some of the studies that have been done on adverse childhood experiences, the initial studies were certainly looking at things such as having a family member with a mental health condition or a family member who is incarcerated, neglect and other forms of abuse.

But what we have found over the years, is that there are other forms of adversity that could have long-term negative effects on their mental health, as well as their physical health, when they enter adulthood. What we know is that being exposed to this level of adversity for an extended period of time, like what was experienced during the course of the pandemic, really can have an impact on the overall stress response systems within these children and being exposed to ongoing stress. We know that's been associated with difficulty with healthy brain development. Because of that interference with good brain development in these children, it certainly sets them up for being at increased risk for various cognitive-related issues once they enter into adulthood. The ongoing stress that they may experience physically can increase their likelihood of developing some chronic medical conditions.

The way that often presents, and it's often hard for a lot of adults to be able to pick up on whether or not a kid may be manifesting some of the early symptoms of prolonged to ongoing stress and adversity, but what we see in kids, and what I certainly saw as a child's psychiatrist and an increase in such behaviors over the time of the pandemic, was kids presenting as being more irritable, more clingy, having difficulty focusing or engaging in some problematic behavior, such as bedwetting and being disruptive in class. Also, having these physical complaints, such as stomachaches and headaches. Oftentimes, some kids were having frequent infections, being ear infections or other issues because their immune system was weakened because of this ongoing stress response that they were experiencing. Significant, significant effects, both mentally and physically.

Dr Bhargava: It's just terrible how all of these experiences stack up and just make a bigger and bigger difference. Just to your point about stress and physical disease and mortality and morbidity, I mean, there's direct links to that, even as adults. The weight is carried for a very, very long time.

Dr Crawford: That's right. It's unfortunate that it's carried for so long because there are so many opportunities along the way for these kids to be able to receive some form of intervention. But if we delay intervening on addressing some of these sources of stress and adversity and how it can impact their mental health, then it just sets them up for an adulthood in which they are experiencing medical illness. They're experiencing, unfortunately, early death because of the lack of intervention here. It's so important for clinicians, who are working with kids, to intervene early on. Some of the things that they could do to intervene early on, especially when it comes to our young kids, is to engage in screening within the primary care setting. Kids are often going to see their pediatrician on a regular basis for well-child checks. Those are important opportunities to talk about some of the stressors that the kids are experiencing and to see if it's needed for them to get some mental health intervention.

As I mentioned earlier on in our conversation, the PSC-17 is a great screening tool to use in the primary care setting because it's able to screen for a variety of different conditions, such as ADHD, mood disorders, as well as some problematic and disruptive behavior-related disorders, such as adjustment disorder, conduct disorder and oppositional defiant disorder. If you have specific concerns with regards to the kids that you're seeing in clinics, such as depression, there's a PHQ-2, which is a really quick screener that you could do. It just simply asks 2 questions during a visit that you have with a pediatric patient can really go a long way. There's also the SCARED, which is a commonly used rating scale for anxiety. Then lastly, the Vanderbilt Rating Scale, which we routinely use to assess for the signs and symptoms related to ADHD that both parents can complete, as well as school teachers.

Dr Bhargava: Wonderful. Wonderful. Let's pivot to what we can do as providers. I know that one area we have used to increase access is telemedicine, but that has some limitations. Isn't that correct, Christine?

Dr Crawford: Yeah, when we quickly pivoted to telemedicine during the beginning of the pandemic, it was a really great opportunity to continue to provide access to mental health supports. Also, during that period of time, more people, more kids were experiencing mental health-related symptoms. It was good that we were able to be able to increase access to mental health supports by the use of telemedicine.

However, the reality is just that telemedicine, for some, has been difficult to access for a variety of different reasons. Even though in primarily under-sourced regions, such as rural parts of the country in which there aren't access to child psychiatrists, you can imagine parents wanting their kid to be seen by a child psychiatrist and having the telemedicine option they'll be really excited and happy about. But if you're living in an area in which there is unreliable internet, and there are difficulties having access to the technology to allow for telemedicine visits, such as laptops and having the technological literacy to be able to connect to all of these telemedicine platforms, we could see it certainly contributing to some difficulties being able to access telemedicine services.

Paying for reliable internet can be difficult for some people. There could be some financial limitations that they may have in order to be able to get all of the resources and tools that they need in order to have their kids seen via telemedicine. Also, the reality is that there are some parts of this country that wasn't really set up to have good quality broadband internet access, kind of a practice referred to as digital redlining, where you're looking at certain communities in which the infrastructure isn't as sound, or as reliable in regards to internet, compared to more affluent parts of the country. That's something that's certainly important to address.

Also, when it comes to telemedicine, you're doing this from home. A lot of these individuals are taking these calls, connecting to their provider over video from home. They really don't have the same access to the sense of privacy and confidentiality that is often afforded to them when they are engaged in in-person visits. If the privacy and confidentiality issues are present, that can create a tremendous barrier to being able to fully access and fully assess and fully understand what it is that the kid is going through because they may be withholding some information because of the setting in which they're engaged in the call.

But what's great is that telemedicine certainly is here to say because it has benefited a number of patients. The barriers, such as transportation, have certainly been eliminated with regards to trying to get into in-person visits, or any childcare-related issues in terms of having to take time off of work or having to leave the home and leaving other kids behind as you're bringing your child for these appointments. There certainly are some benefits, as well as some drawbacks when it comes to telemedicine, for sure.

Dr Bhargava: Absolutely. Well, we just have a few minutes left here Christine. I just want to hit a couple of these really important points to give pediatricians and clinicians a little bit of direction in terms of what they can do. What can they do in their offices to make sure that there's actually that, to your point, mental health is identified quickly? Then, of course, what are some ways that they can help pediatric access to mental health systems?

Dr Crawford: I think what clinicians can certainly do is look at ways in which you can normalize the conversation around mental illness. I think what is encouraging is that the American Academy of Pediatrics has put out recommendations that providers should screen for mental health symptoms at each and every visit. That's incredibly important because it allows for that early intervention to occur. By doing it at every visit, talking about mental health, you're normalizing the conversation around mental health and normalizing it in a way such that kids learn and understand that mental health is part of overall health and wellness. To make sure when you're having these conversations with kids, to avoid using stigmatizing language because we don't want people to feel as though they are less than or have worries about being treated differently or perceived as being treated differently or being discriminated against because of their mental illness. Words really do matter. It's important for us to keep that in mind.

Also, to talk about what strategies the kids are using with regards to managing their mental health symptoms and to encourage the parents and the caregivers who are bringing their kids in for these appointments, to talk about some of these coping strategies that are already being used by the child, as well as the model conversations about how it is they talk about mental health.

The other thing is, I think it's important for clinicians to talk about the importance of using some of the resources that are available at school for mental health supports. Whether that being advocating for mental health days and talking to their patients about how to recognize some of the signs and symptoms of when one isn't doing well and to know the importance of taking a break and to how to have that conversation with school administrators and teachers. I do think that's an important conversation to have. Then also, the other thing that I'll mention is for mental health providers, as well as primary care providers and clinicians, to understand that there are a number of innovative tools that are available right now to help manage mental health symptoms. Doing some research about some mental health-related apps that you can share with your patients could also be something that could really go a long way during these conversations with your pediatric patients.

Dr Bhargava: Those are great points, Christine. I think one area that is hopeful is that we, at least, are having the conversations. I mean, this was, obviously with your numbers, those are pre-pandemic or maybe early pandemic and now, yes, there's exacerbation of it, but at least we know that mental health is a centerpiece and we're looking and, I think, raising awareness and education around it is one of the first steps to make change. Thank you so much for all of this information. As we close out, is there anything else that you would like to say to our audience as we listen, and we've listened to your wonderful presentation today?

Dr Crawford: Absolutely. I just can't stress the importance of having these conversations often and having these conversations with the intention to fully listen to what it is that our kids are doing, what they're experiencing, how they're managing and coping with all of these stressors, and to continue to ask and inquire about how they're feeling. We got to keep doing that, even when we don't have the time. We need to just continue to be mindful of our own mental health as well because we want to be well and healthy to take care of our kids and to continue these conversations.

Dr Bhargava: Well, I love that. You're absolutely right. To screening the kids, knowing about this, knowing the impacts and the long-term impacts that mental health can have, knowing about toxic stressors and inequities around that, and of course, looking for solutions and making sure we have those conversations. Lastly, love that, take care of your own mental health as well. To be the best provider you can be, it starts with you. You can't take care of the patient unless you take care of yourself. Right, Christine?

Dr Crawford: That's right.

Dr Bhargava: On that note, I just wanted to thank you so, so much and thank you to the audience for listening to this conversation today. Until next time, this is Dr Hansa Bhargava.

This transcript has been edited for style and clarity.

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