Helping Primary Care Providers Meet the Mental Health Needs of Children

Mental health issues among children and adolescents have increased under the ongoing demands of a pandemic which continues to exacerbate risk factors, such as isolation and loneliness, for poor mental health.

A Kaiser Family Foundation report found more than 25% of high school students during the pandemic have reported worsened emotional and cognitive health, and more than 20% of parents report worsened mental or emotional health in their children aged between 5 and 12 years.

As emphasized in the report, these high levels of mental health issues in children and adolescents are not new to the pandemic. Between 2018 and 2019, for example, about 5.2 million (8%) children between the ages of 3 and 17 years had an anxiety disorder, 2.3 million (4%) had a depressive disorder, and 5.3 million (9%) had attention deficit disorder or attention deficit/hyperactivity disorder (ADD/ADHD).

These numbers are just a snapshot of a growing issue that if not better addressed threatens to affect the health and well-being of millions of children well into adulthood. If left unchecked, through their lifetime, poor mental health can have a cascading effect on the lives of their caretakers when young, their own children when older, and event costly demands on the health care system—which could grow to be substantial.

A recent report from the RAND corporation found that an estimated $12 billion a year is spent on mental health care for children and adolescents, with adolescents aged 12-17 years accounting for 60% of the costs, children aged 6-11 years 35% of the cost, and preschoolers aged 1-5 years accounting for 5% of the cost. The report also highlighted a shift toward outpatient treatment over the past 15 years, which comprises about 60% of all mental health expenditures with inpatient care accounting for about 33%.

These numbers only reflect health care expenditures for the children and adolescents who receive treatment. The report highlights that of the 9% of children and adolescents who need help for mental health issues, three-fourths are Hispanic and African American, adding to racial disparities in health care. The numbers also don’t capture the costs downstream of unaddressed mental health issues that persist into adulthood where they often are more intractable.

Meeting the mental health needs of these children and adolescents is critical. As the gaps in mental health care persist, the challenges of recognizing and treating mental illnesses are increasingly falling to primary care physicians, given the shortage of child mental health professionals nationwide, as well as their place as the first point of contact for these youth. However, family physicians, pediatricians, and other front line primary care physicians often lack the education and resources to know how best to address these mental health issues in their patients. Various models are being looked at and used to help primary care providers meet the mental health needs of their patients, such as collaborative or integrated care models.

Another model that has expanded into many states are child psychiatry open access programs. At their core, these educational and resource-driven programs help primary care providers know quickly—same day—what help is needed for any given child.

John H Straus, MD, who started the first child psychiatry open access program in Massachusetts in 2004, and is now President of the National Network of Child Psychiatry Access Programs, said he sees mental health issues in the same light as something like asthma.

“If everyone with asthma had to go to a pulmonologist, we’d be in big trouble,” he said, suggesting that, like mental health, the high prevalence of asthma would incur too high of a cost and access burden if specialty care was needed to treat all cases. Instead, 80% to 90% of treatment for asthma is done by primary care providers. “We want mental health to become the same, and we think it can be,” he said, adding that psychiatrists would only be involved for children with more severe mental health issues that require a higher level of care.

Child Psychiatry Open Access Programs

At the heart of child psychiatry open access programs is providing same day access to resources for mental health issues seen in the primary care clinic. This is done typically though same-day telephone consultation with a psychiatrist via a dedicated hotline who can help with diagnosis, or medication changes, or referrals to a behavioral therapist.

This is the foundation of most of the child psychiatry open access programs found in most US states. (A list of programs by state can be found at www.nncpap.org.) Some programs, which Dr Straus thinks are the most successful, also provide a one-time in-person or telehealth consultation with the child and family when needed. These programs do not, however, provide psychiatric care or therapy.

“These programs are largely a resource tool,” said Dr Straus, who is a pediatrician, saying that the program was started given the insufficient training and understanding pediatricians had about mental health issues that often led to long delays in these issues being addressed. With the program in place, pediatricians and other primary care providers now incorporate screening for behavioral health into clinical practice much the same way they do for measuring height, weight, and blood pressure.

“The biggest impact of these programs is to normalize mental health within primary care,” he said.

Joanna Quigley, MD, associate medical director for child & adolescent services, Ambulatory Psychiatry, University of Michigan, who devotes one day a week to consulting for the state child and adolescent and perinatal psychiatry access program in Michigan called MC3 program, thinks one great benefit of these programs has been to empower primary care providers to feel more comfortable with identification of even basic mental health concerns.

She underscored the programs focus on leveraging the resources in the primary care settings rather than relying on face-to-face interaction with specific patients. For example, she highlighted the importance of educating providers on the impact of trauma on a child’s life. “Kids that present with being ‘behaviorally difficult’ or ‘hard to treat ADHD’ may actually be a child who has dealt with significant trauma, and that needs a totally different approach to care,” she said.

Another important function of the access program, she said, is to help bridge the care of a child who returns to the primary care setting after an inpatient hospitalization for a mental health issue. “This is a huge need for families who are waiting to get in to see a child psychiatrist,” she said.

To date, the programs appear to be doing what they set out to do—improve access to mental health services for more children and adolescents who need them. A 2019 study by researchers at the RAND Corporation that looked at multiple years of national survey data of the programs found that children residing in a state with an open access program were significantly more likely to receive mental health services compared to children residing in a state without an open access program or only a partial program (ie, offered only in certain counties in a state). By 2016, 12.3% children received mental health services in states with open access programs compared to 9.5% of those in states without a program and 10.9% in states with only a partial program. The study also noted that the percentage of children receiving mental health treatment grew from 8.4% in 2003 (a year before the first open access program in Massachusetts) to 9.5% in 2007, 11.1% in 2011, and 11.4% in 2016.

Dr Straus said he’d like to see these programs now move beyond their sole focus on access to care to include improving quality of care for children with mental health needs. He and his colleagues are currently working on doing this in Massachusetts where they would like to see primary care practices use a collaborative care model that uses measurement-based care to track their patients. “One of the pieces of this approach is that if the patient is not getting better, you have the ability to have a consultation with a specialist and be proactive around patients with mental health as well as substance use.”

Funding Critical to Sustain and Grow Programs

Fundamental to sustaining and growing these programs is ensuring ongoing revenue sources. Both Drs Straus and Quigley emphasized the ongoing challenge of funding these programs to make them, in Dr Quigley’s words, long-term fixtures.

The bulk of the funding comes from the state via legislative avenues, or through grant monies. For example, in Massachusetts, the state legislature passed a law mandating all commercial payers in the state to pay into a fund to support the programs based on a formula already used to fund childhood vaccines. Other states, said Dr Straus, are coming with other funding streams including using fee-for-service consultation codes. However, he cautioned that such an approach will not be sufficient to fully fund consultants needed for the programs and advocated instead for a value-based payment approach.  Dr. Straus believes that this is best done by having all payers divide up the cost of the program to provide an annual payment as is happening in Massachusetts and Washington.

On the federal level, some programs have been awarded funds via the Health Resources & Services Administration (HRSA) of monies available through the American Rescue Plan Act (ARPA) to expand pediatric mental health care access. According to Dr. Straus, the nearly $80 million over 5 years available through ARPA, combined with the money Congress previously gave to HRSA, can provide all states the seed money needed to start these programs. To date, he said, with HRSA funding 41 states, only 4 states are without an any open access program.

Given the broad participation by most states to support these programs, Dr Straus believes the programs will become a universal need in pediatric primary care to support, in particular, behavioral health integration as well as to address the shortage of child psychiatrists. “Payers and managed care plans are going to be increasingly asked to provide funding,” he said. As such, he urged all payers and plans to consider what open access programs are available in their states.