On August 27, The New York Times ran an article by Matt Richtel titled “This Teen Was Prescribed 10 Psychiatric Drugs. She Is Not Alone.” It documents the practice of “polypharmacy”: prescribing multiple medications—most of which have not been tested either in children or in combination with one another—to manage young patients’ depression or anxiety.
That young patients are being prescribed potent cocktails of untested drugs is obviously wrong. The question is, how did we get to this point, and what can we do about it?
In the wake of the Texas school shooting tragedy, your young patients–and their families–may be experiencing anxiety that can affect normal functioning. That anxiety can manifest in many ways, from reluctance to go to school to increased aggressive tendencies.
In fact, pediatric primary care providers (PCPs) have been observing the effects of news consumption on their young patients for years now. The spike in anxiety at the beginning of the Covid pandemic is another example. Families may be experiencing trauma as they watch scenes of devastation and displacement in Ukraine. Every act of terrorism or mass violence inspires more fear. The examples go on.
As your families’ trusted PCP, you can influence how patients and families deal with anxiety over recent events and the continuous barrage of bad news that characterizes today’s media culture.
Many patients who have mental health conditions need talk therapy in addition to the treatment you provide as the pediatric primary care provider (PCP). If you practice in an area where therapists are available, we hope you have developed referral relationships, as you learned in your REACH training. You may also see patients who are already working with a therapist.
In either case, the communication between you and the therapist makes a huge difference in the quality of care the two of you provide.
To learn how PCPs and therapists can collaborate to improve the mental health of children and adolescents, we talked with clinical psychologist Kevin Stark, PhD, a founder of The REACH Institute’s CATIE program, and pediatrician Hilary Bowers, MD, director of behavioral and mental health services at Children’s Primary Care Medical Group, a large pediatric practice in San Diego and Riverside counties in California.
Children with mental health diagnoses may need special accommodations in order to succeed in school. Patients with attention-deficit hyperactivity disorder (ADHD) or autism come immediately to mind. However, children with depression and anxiety disorders may also struggle in the classroom.
Pediatric primary care providers (PCPs) and therapists can help families get the school accommodations their children need. Mark Wolraich, MD, REACH faculty member and retired professor of pediatrics at the University of Oklahoma Health Sciences Center, emphasizes that children are best served when professionals take a team approach to mental health care.
2021 brings big changes to coding for mental health visits in pediatric primary care! The new coding guidelines issued by the Centers for Medicare and Medicaid Services (CMS) reduce the documentation burden and increase the levels of payment (work relative value units or wRVUs).
More than 40,000 children have lost a parent due to COVID-19. Black children, who constitute 14% of children in the US, are 20% of those who have lost a parent. Chances are good, then, that some of your patients have been through one of the most significant losses they will experience in their whole lives. The support they receive now to grieve in a healthy way can make the difference between their ability to thrive and their descent into adverse outcomes ranging from school failure to death by suicide.
Last week I saw two children, both African American, who were having suicidal thoughts. In neither case did the child or the parents come in asking for mental health support.
One, a 13-year-old girl I’ll call Simone, wrote on her PHQ-9 depression screener that she had attempted suicide. In our interview, she revealed that she had had sex with a man she met online and that she had been cutting herself. Yet the reason she and her parents came in was an ADHD medication check!
Pediatric primary care providers (PCPs) need to realize that African-American families may not seek help for mental health issues. The reasons for the lack of disclosure are rooted in the stigma around mental health in the African-American community. The stigma, in turn, is rooted in the trauma associated with being Black in America.
Eating disorders are life-threatening mental health conditions—and they are not limited to affluent white girls! Eating disorders affect people of lower socioeconomic status, members of non-white ethnic groups, preteen children, and boys. LGBTQIA young people are at particular risk.
DSM-5 defines four main categories of eating disorders: anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant/restrictive food intake disorder, along with several atypical disorders.
Asked the top three things a pediatric primary care provider (PCP) needs to know about child trauma, Brooks Keeshin, MD, said, “Trauma happens. That’s numbers 1, 2, and 3.”
In fact, up to 80% of children experience trauma by the time they are 18. A large body of evidence indicates that childhood trauma affects physical and mental health, both short term and long term.
Dr. Keeshin, a child abuse pediatrician and child psychiatrist, is developing a new REACH Institute course to teach PCPs to assess and treat child trauma.
“Trauma reactions can look like other mental health conditions,” said Dr. Keeshin. “Traumatic stress can present with symptoms of ADHD, depression, or anxiety. If the pediatrician knows a child has been exposed to trauma, that changes what they do. But first they need to know.”
In a study sponsored by the Centers for Disease Control and Prevention, 10.8% of adults reported having been physically abused as children, and 11.1% reported psychological abuse. Infants and young children are at greater risk than older children; neglect is more commonly reported than physical, psychological, or sexual abuse, according to the National Child Abuse and Neglect Data System.
As a pediatric primary care provider (PCP), you play a vital role in detecting and preventing child abuse and neglect.
“Parents who are going through a divorce really want to believe their children are OK,” said Lisa Blum, PsyD, a licensed clinical therapist on the faculty of The REACH Institute’s CATIE program. “They’re terrified that they’re hurting their kids. So if Sally is doing her homework and Johnny isn’t acting out, the parents think, ‘Whew, good, they’re fine!’ But often they’re not fine.” Though divorce rates in the US have been declining for years – including, according to early reports, during 2020 – the rates are still high. Each divorce or separation brings loss, disruption, and pain to any children involved.
If you’re like most pediatric primary care providers (PCPs), you’ve seen an increase in child mental health issues due to COVID. Research shows that the pandemic, with its consequent disruption and isolation, has increased adolescents’ risk of trauma, depression, and anxiety. Families are dealing with grief, the anxiety of whatever “school” means this week or this month, and, in many cases, loss of income. Families of color and low-income families have been hardest hit by the pandemic itself, by the economic and social fallout, and by the attendant impairment of mental health. And now come the holidays.
Once pediatric primary care providers (PCPs) recognize the importance of having conversations about race with their patients and families, the next question is how to begin.
“The first thing clinicians need to know about racism and discrimination is how important it is to talk about it.” Open, honest, and effective conversations about race and racism are crucial to young people’s mental health.
As suicidality among adolescents generally has declined in the past three decades, suicide attempts among Black adolescents have risen, according to a November 2019 article in Pediatrics. A report to the Congressional Black Caucus (CBC) says that rates of suicide death have risen more for Black youth than for any other racial or ethnic group. A growing concern is that Black youth are less likely to report suicidal thoughts but more likely to attempt suicide; Black males are more likely to suffer injury or death as a result. Suicidality is also increasing among younger children. The reasons for these changes are not clear. However, the risk factors for suicidality and underlying mental health conditions among Black children and youth are myriad.
In treating young patients who have chronic physical conditions, health care professionals focus — as they must — on alleviating the physical suffering caused by the disease. However, as a graduate of the REACH course Patient-Centered Mental Health in Pediatric Primary Care, you know the importance of supporting the mental and emotional health of young patients and their caregivers. A new article in Pediatrics highlights the importance of mental health care for families dealing with chronic illness.
The American Academy of Pediatrics (AAP) has released a new policy and an accompanying technical report on mental health competencies for pediatric clinicians. REACH faculty member Cori Green, MD, MS, is a lead author of both documents. We asked Dr. Green, director of behavioral health education and integration at Weill Cornell Medicine in New York City, what the AAP policy and technical report mean for alumni of the REACH program Patient-Centered Mental Health in Pediatric Primary Care. “I hope they’ll be excited to see that what is being endorsed by AAP is essentially what they were taught in their REACH training,” Dr. Green said. In the technical report, the REACH course is described as a promising practice in continuing medical education.
“When it comes to school refusal, getting all the adults on the same page is the bottom line,” said James Wallace, MD, a REACH faculty member. “Until you have that, you have nothing.” Dr. Wallace, who teaches child psychiatry at the University of Rochester (New York) Medical Center School of Medicine and Dentistry, described an approach to school refusal that unites primary care providers, schools, and mental health professionals in helping families make choices that support regular school attendance. “An evidence-based approach to school refusal, and the anxiety or depression that usually underlie it, includes cognitive behavior therapy and sometimes medication,” said Dr. Wallace. “But there’s a third piece: getting all of the adults involved, including the parents, to address the social-emotional components of school attendance in a consistent way.”
According to the National Center for Education Statistics, 92% of public schools had formal active shooter plans in 2016, and 96% conducted lockdown drills. These measures are intended to keep children safe, but they may do as much harm as good. The title of a September 4 New York Times article sums it up: “When Active Shooter Drills Scare the Children They Hope to Protect.” We asked REACH faculty member Jasmine Reese, MD, MPH, about how students react to active shooter drills and what pediatric primary care providers (PCPs) can do. Dr. Reese is Director of the Adolescent and Young Adult Specialty Clinic at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida. “We have yet to see data on whether these drills are causing more anxiety and other mental health issues among students,” said Dr. Reese. “But it seems clear in practice that they can either cause anxiety and depression or exacerbate existing issues.”
“Going to college is exciting, but students need to know that this experience, though positive, may also be stressful,” said REACH faculty member Elena Man, MD. Dr. Man recommends resources and strategies that pediatric primary care clinicians can use to prepare patients for this significant transition to a new environment for learning, living, and friendships.
“It’s not just that we’re more aware of adolescent suicide,” said Michael Scharf, MD, chief of child and adolescent psychiatry at the University of Rochester Medical Center and a REACH faculty member. “The rate really is going up. Teen suicide is still rare, but it’s increasing.” Primary care providers (PCPs) can help teens at risk of suicide, first of all, by being willing to talk about it. “Some people think that asking about suicidal ideation makes the kid more likely to act,” said Dr. Scharf. “But evidence shows that asking either has no impact or has a relieving effect; it frees the patient to talk about the issue.” “You need to think ahead of time of what to ask and how, so you feel comfortable,” said Dr. Scharf. “You need a go-to way to assess risk and how likely the kid is to follow through.” (See Resources below.) The assessment results can range from “nothing to do here” to “send this kid to the emergency department.” “The tricky part,” Dr. Scharf said, “is what to do in between.”
Some pediatric primary care providers (PCPs) are nervous about providing mental health services because they are not sure they can be paid. However much they may want to treat patients with mental health disorders, they can’t afford to practice for free! Evaluation and management of mental health conditions is time-intensive. PCPs wonder, “How can I spend 90 minutes doing intake?” Those who work in large healthcare systems worry about the WRVUs (work relative value units) by which their productivity is judged. Providers in small practices worry about getting paid for visits that involve primarily talk. “Primary care providers absolutely can be paid for mental health care,” said Dr. Eugene Hershorin, a coding expert in the Pediatric Department in the University of Miami Health System and a REACH Institute faculty member.
“Pediatric primary care providers can have a big impact on child mental health simply because we see children early and often,” said Dana Kornfeld, MD, REACH board member and associate clinical professor of pediatrics at George Washington School of Medicine. Dr. Kornfeld, who practices at Pediatric Care Center in Bethesda, MD, endorses the use of cognitive behavioral therapy (CBT) techniques in primary care to nip potentially crippling anxiety in the bud.
Alana, age 17, comes into your office complaining that she can’t sleep at night and struggles to stay awake during school. If she can, she sleeps until noon or later on weekends. “Diagnosis of sleep disorders is often easier with teens than with younger children, as long as you ask the right questions,” said Robert Kowatch, MD, a REACH faculty member who is a pediatric sleep expert at Ohio State University Medical Center/Nationwide Children’s Hospital.
Alana, age 17, comes in complaining that she is tired all the time and struggles to stay awake during school. Or perhaps it’s six-year-old Miko, whose mother tells you that Miko avoids going to bed and often gets up in the middle of the night. Miko says he doesn’t feel sleepy, but his teachers say he is often inattentive and sometimes quarrelsome. The most common sleep problems among young patients are these and other forms of insomnia or insufficient sleep, according to REACH faculty member Robert Kowatch, MD …
Ryan, age 12, has missed almost three weeks of school so far. He complains of nausea and headache most school days and has to be cajoled into getting out of bed, but his mother says he is fine on weekends. The mother, who is eight months pregnant, is frantic; she can’t afford to take any more time off work before she delivers. School refusal can have serious consequences. On the short term, the child falls behind academically, both the child and the family experience disruption and distress, and there can be legal and financial ramifications. Long-term consequences for school refusers include violent behavior, school dropout, early marriage, and unemployment. “The main goal of treatment is to get the child back to school as soon as possible,” says Lisa Hunter Romanelli, PhD, REACH Institute CEO and clinical psychologist. “Being absent from school is highly reinforcing.” Like many school refusers, Ryan presents somatic complaints. After you rule out physiological causes– not only for these complaints but also for any underlying conditions that can produce depression or anxiety–what’s next?
As you’ve dealt with back-to-school (and back-to-sports) visits, you probably have been challenged by the gap between what’s needed and what’s practical. This visit may be the only time you see this child this year. You know that emotional and mental health is as important as physical health. But you have only so much time for each check-up. Screening tools are a big help…
“We have kids who come in here on three, four different medications,” says Dr. Elizabeth Wallis, MD, “and we don’t know why. We don’t know what data were used to make those decisions.” Dr. Wallis, director of the Foster Care Support Clinic (FCSC) of the Medical University of South Carolina and a REACH faculty member, was expressing just one of the challenges of treating children and youth in the foster care system.
“For these straightforward cases, when you can identify uncomplicated ADHD in patients without co-occuring depression or anxiety – well, everyone in primary care should be able to do this.”
In the absence of a single child and adolescent psychiatrist anywhere in Cape May County, New Jersey, The REACH Institute training enabled Rainbow Pediatrics to help families who had nowhere else to turn.
“The REACH Institute Video Testimonial: Hilary ”