The statistics are familiar, repeated regularly from national podiums: 7.7 million youth, ages 6 to 17, are estimated to have at least one treatable behavioral health disorder, yet only 51% receive care. By age 24, 75% of all behavioral health conditions have already manifested. These conditions cost $193.2 billion in lost income each year and are estimated to cost the global economy $16 trillion by 2030, according to the Lancet Commission on Global Mental Health and Sustainable Development.
While there's been progress in kick starting initiatives focused on behavioral health, statistics remain high and communities are struggling. "We need to better integrate our approach to health care," says Gary Blau, Ph.D., executive director of the Hackett Center for Mental Health in Houston. "Mental health is part of overall health. Separating these into two different systems has not worked. We do a better job when we integrate the mind and body."
Blau is an advocate for systems of care—the "philosophical underpinning" and framework for effective community-based services and support for children and youth. Research shows of children with trauma who were part of a system of care after one year, 48% had reduced school absences, 41% experienced an increase in school performance, and 15% improved their competence in classroom tasks. Mental illness is a pediatric illness-early detection and treatment lead to the development of healthy adults with less impact on the health care system.
An ideal behavioral health system of care has parameters set federally, but the details are determined locally, tailored to residents in the community. Blau oversaw the implementation of the Children's Mental Health Initiative (CMHI) under the Substance Abuse and Mental Health Services Administration (SAMHSA).
CMHI is a national program that provides grants to states, communities, tribes and territories to implement systems of care. The federal government set general guidelines for recipients, and programs are fine-tuned to meet the needs of individual communities. The funding is intended to jump-start initiatives in communities most in need.
"It's difficult, if not impossible, to keep kids healthy and well if we don't also address their mental health," says Amy Herbst, M.S.W., vice president of Mental and Behavioral Health at Children's Wisconsin in Milwaukee. "The goal is to meet kids and families where they are, bring behavioral health care close to home, and provide more services in the school, outpatient clinics and pediatrician offices, and use technology to reach kids with access barriers because of geography."
Here's how integrating mind and body can keep kids out of high-cost levels of care and lead to healthy future adults.
Creating capacity
"One of the biggest issues we have is mental illness is so prevalent, and the capacity and access to care remains a significant barrier," Blau says. More children in the U.S. have or have had a diagnosable mental health disorder than there are children with cancer, diabetes and AIDS combined.
Some studies show the U.S. could be short more than 15,000 psychiatrists by 2025, as demand continues to increase and because many current mental health professionals are over the age of 55. "We do not have enough social workers, marriage and family therapists or other clinicians to serve these kids," Blau says.
In Wisconsin, child and family therapists require 3,000 hours of supervision before obtaining their license, a barrier to most who must also work to sustain themselves while undergoing supervision on a part-time basis with no pay. It can take five or more years for a therapist to complete the requirement-a long time to get new therapists into the workforce, especially in states experiencing provider shortages and long wait lists for families.
The Therapist Fellowship Program at Children's Wisconsin aims to solve the capacity problem. The goal is to introduce at least 31 new child and family therapists into the workforce by 2024 by offering trainees a salary and benefits to earn supervision hours. Twenty-five will work on a full-time basis. The first group of five trainees started in the summer of 2019.
The program should take about 18 months, shaving off more than three years while giving trainees exposure to trauma-informed care and youth in all settings of the Wisconsin system. Upon completion of the program, there are full-time therapist positions waiting for them at Children's Wisconsin, making the transition and onboarding process seamless.
The program immediately enhances Children's Wisconsin's reach to kids in need-the first group saw 370 new clients in the first year of the program. At its peak, the Therapist Fellowship Program will add about 1,000 patients per year. Over the course of five years, 31 new therapists will provide an additional 44,000 hours of therapy and 3,500 new patients.
"That is tremendous growth and access for our community," says Tracy Oerter, M.S., director of Mental and Behavioral Health Services at Children's Wisconsin. "We're doing this across the state. This is providing access in our urban and rural communities that have a whole different level of access challenges in terms of distance, weather and lack of providers."
Helping families navigate the system
Low capacity walks alongside other system complications: poor reimbursement, long waiting lists for care, stigma, lack of training among non-mental health professionals and an all-around complex system structure. The Cameron K. Gallagher Mental Health Resource Center at the Children's Hospital of Richmond at VCU in Virginia aims to help by bridging behavioral health care services with "support, referrals and encouragement," with the understanding that the system can be confusing and stressful, particularly for families feeling the strain of a mental health disorder.
Navigators help families maneuver pediatric behavioral health services, modeled after the experiences of families who have already navigated the system.
"It started with the idea that access to behavioral health services is challenging," says program manager Rachel Reynolds. "We designed a service to be a GPS for mental health services. Family navigators can tell you what's out there, who's going to take your insurance, if they specialize in certain programs like anxiety or eating disorders. They work with families to find the best resources for their needs."
About two weeks after connecting with the resource center, navigators follow up with the family, confirming appointments and directing them to supplemental resources. Those resources include education for parents of children with behavioral health challenges to help them work through stigma.
Resources are driven by best practices and experts in the field, which Reynolds says help parents understand what their child is going through. Navigators continue to work with families for as long as the family feels they need support.
"One of the hallmarks of systems of care is that it's family-driven and youth guided," Blau says. "Families need to be involved in treatment planning. Youth will tell you how they can best be served. We have to engage young people and families in their own care and the care of others."
Integrating care
Statistics repeatedly show that people with medical conditions are more likely to have a diagnosable mental health disorder. Part of the systems of care philosophy is to account for behavioral health in the place where kids are already going-their primary care doctor.
Blau says pediatrics generally does a better job at the wraparound approach to health care than the adult world, involving families and schools in a child's physical care. There's room for improvement, however, in behavioral health. "Primary care and mental health care systems can work in concert with each other," Blau says. "The first place that a child will be taken to address a mental health concern is their pediatrician 75% of the time."
Founded in the belief that integrated care leads to earlier diagnosis, Blau recommends children's hospitals have a mental health professional working as part of the team for all subspecialties within pediatrics. That team member requires a status level within the hospital system that allows for behavioral health consultations to be conducted alongside physical health visits. Just like collecting data on body weight and blood pressure at each visit, there should be screening questions for behavioral health.
Blau says this allows providers to know when things are getting better or when a patient's mental health care needs course correction. Children's Wisconsin is moving toward this practice. "Every checkup, every doctor visit, every interaction we have with families, we want that to include a conversation around mental health, whether it's a presenting issue or not," Herbst says. "If a patient comes to us for diabetes care, we expect the team that takes care of their diabetes is also asking questions and connecting them, if necessary, with mental health care."
Herbst and Oerter practice a community-based approach to behavioral health in Wisconsin. One program puts therapists in 50 public schools across the state, with another eight to 10 being added in the upcoming school year.
Students have access to individual and group therapy on school grounds. "Not only does each community and school district have its own needs and culture, each school and sometimes each grade does too," Oerter says. "We integrate into the school and become part of the team. We're not just a therapy office down the hall or ‘that therapist from Children's.'"
Increasing access with telehealth
Children's hospitals serve larger geographical areas than adult hospitals-only about one of every 25 hospitals in the U.S. is a children's hospital. This presents an access challenge for some children's hospitals that can serve multiple states. "A good behavioral health system is easily accessible and has enough capacity to treat anyone that needs help," Blau says. "Research is clear that serving people through telemedicine is just as effective, if not better, than serving people face-to-face."
Established telehealth programs demonstrate increased reach, particularly in remote areas and where transportation to a provider can be difficult to access. The COVID-19 pandemic necessitated children's hospitals focus more resources on telehealth, highlight its benefits and find areas of opportunity. Children's Richmond had been using telehealth prior to the pandemic but saw 80% of outpatient visits go virtual to reduce spread of the virus. The result was a sharp decline in the no-show rate. Just a couple weeks into the pandemic the hospital's missed appointment rate dropped below 10%.
An added benefit Children's Richmond's mental health providers experienced was insight into family life they would not get otherwise. "We're seeing some nice outcomes with telehealth," Reynolds says. "In-person visits can be helpful for the clinician, but it's also helpful to see the home environment."
At Children's Wisconsin, telehealth was less established prior to the pandemic, especially for behavioral health. Providers had to be quickly trained on a new way of providing care. "The learning curve was tremendous," Oerter says. "Then on the patient and family side, we experienced various levels of buy-in, trust and comfort not only with the technology, but also with the thought of having a mental health professional dialing into their homes."
The team in Wisconsin experienced trouble reaching families for appointments, same-day cancellations and patients not cooperating via digital platforms. Yet, Oerter is hopeful telehealth will help reach families in remote areas and keep appointments during school snow days or over the summer months. "It's not a one-size-fits-all model because not all families are the same," Oerter says. "As we refine our telehealth workflows, we will be able to manage some of that. There are a lot of situations where this is going to be a wonderful addition to our traditional face-to-face model."
A framework that works
Systems of care has demonstrable positive outcomes-data shows kids in these programs have less suicidal ideation, have been kept out of higher-cost levels of care, remained safely in their homes, and had a reduction in negative interactions with law enforcement. And it takes a village. "We must attend to the importance of caring for every child's mental health," Blau says. "Policy makers, providers, families, we're all going to have to address the issue together because it's not going to go away. It's actually going to be a significant challenge for our country in the years ahead."
Despite the challenges, many working in behavioral health share a sense of optimism. The carving out of funding and resources, and development of community-specific programs is grounded in the systems of care philosophy by putting the well-being of the whole child at the forefront. "Mental health is health," Herbst says. "When you start from that idea, it allows you to have mental health care be part of how you take care of all of your kids."
