The stress, uncertainty and fear the COVID-19 pandemic created has weighed heavily on children. Since the start of the pandemic, children’s hospitals have seen more kids with mental health emergencies present to their emergency departments (EDs).
In 2021, children’s hospitals’ EDs saw a 153% increase in suicide and self-injury cases compared to 2016, according to data in the Pediatric Health Information System®. Kids are facing big challenges, and providers are stretched thin.
But the pandemic did put a spotlight on the importance of mental health for children and youth and the fragility of the pediatric mental health care system. Last October, Children’s Hospital Association joined the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatrists in declaring a national emergency in children’s mental health.
Then in December, U.S. Surgeon General Vivek Murthy issued a nationwide advisory on the youth mental health crisis that was worsened by the pandemic. He called for a “swift and coordinated response” to make sure kids have access to the care they need.
Since then, more than 75 children’s hospitals and 55 organizations have joined Sound the Alarm for Kids, calling for federal actions to support a stronger system of care for children’s mental health.
Ron-Li Liaw, M.D., Mental Health-in-Chief at Children’s Hospital Colorado, sees the declarations as a “relief” to those working in the behavioral health field. Officials are calling it what it is: a crisis. And while the crisis is not new, COVID-19 amplified it and heightened awareness among the public, lawmakers and health care organizations.
“Many kids show early warning signs and are not getting the care that they need at the right place, the right time or with the right care team,” Liaw says. “Then it becomes an emergency, and families must access crisis care in emergency departments. By that time, it’s too late. It’s become a real crisis and impaired that child’s development or functioning.”
This scenario is one pediatric health care providers are all too familiar with. To help remedy it, here are examples in three areas where children’s hospitals are collaborating and implementing programs within schools, expanding the workforce, improving communication and continuing to expand on creative care strategies developed during the pandemic.
Schools as essential partners
Kids spend a lot of time in school, positioning school staff as ideal observers of changing or concerning behaviors and expanding the system of care beyond the medical setting. According to the Hopeful Futures Campaign, 30% of students who receive mental health services receive it in schools, making the education system the most accessed behavioral health delivery system for youth.
“You can’t partner enough with schools—that’s where the kids are,” says Michele Wilmoth, M.S.N., RN, LSN, NCSN, director of Nursing, School Health Services at Akron Children’s Hospital. “They live, eat, work and play at school. If you want to make a difference in a child’s life, you have the most opportunity to do so in a school.”
To better identify and meet student needs, Akron Children’s launched a philanthropically funded, school-based health program using nurse practitioners and telehealth services in 2019. The hospital established the program in 12 districts, and now that in-person learning has resumed, nurse practitioners visit each school at least once a month for consultations.
This includes screening students for behavioral health issues, connecting students to services and completing wellness exams. “We’re helping students and families navigate a complex health system,” Wilmoth says.
The pandemic delayed the program getting traction in schools, and Wilmoth and her team pivoted to address how to meet student needs during virtual school. The team conducted meetings with families using video conferencing so they could have open conversations about a child’s health concerns.
Now that students are in school in person, they are working to ingrain the program in school culture. This program also marked the first time Akron Children’s brought telehealth into schools. When nurse practitioners are spread across multiple sites and buildings, nurse-to-nurse video consults help triage students more efficiently.
In addition to providing care where the students are, school-based behavioral health programs can help children’s hospitals reduce readmissions. At the University of Maryland Children’s Hospital (UMCH), a program connects youths discharging from the psychiatric inpatient unit with a transition specialist to help improve communication among the hospital, schools and the patient’s family.
The transition specialist attends school meetings and creates individualized plans to reduce family stress and improve outcomes for the student. “This intervention has shown to reduce 30-day readmissions, which is important at a time when there are limited inpatient beds and staff to treat youth,” says Sarah Edwards, D.O., medical director, Child and Adolescent Psychiatry Services at UMCH, and assistant professor and director, Division of Child and Adolescent Psychiatry at the University of Maryland School of Medicine. Initially, the program was funded through a grant and has since become part of the hospital’s budget.
'They live, eat, work and play at school. If you want to make a difference in a child’s life, you have the most opportunity to do so in a school.'
In addition to school-based behavioral health efforts, Liaw says behavioral health education programs could be introduced early in a child’s education, with behavioral health curriculums starting as early as kindergarten and pre-K. This practice could serve two purposes.
First, trained professionals would teach kids from an early age how to put words to their feelings and alleviate discomfort in talking about mental health. Second, it would introduce more youth to the field of psychology and may spark a lifelong career.
“Build programs from kindergarten through grade 12,” Liaw says. “By the time they get to high school, they’ve essentially taken Psychology 101. They can start earning credits and understand different career paths.” Liaw says doing so might increase interest in careers in the behavioral health field across more diverse populations.
Creative workforce expansion
A workforce shortage and increase in need for services is straining a pediatric behavioral health system that is already challenging to access. For example, a 2019 study published in Pediatrics found there is an average of 9.75 child psychiatrists per 100,000 children in the U.S. The American Academy of Child and Adolescent Psychiatry projects the country needs 47 child psychiatrists for every 100,000 kids ages 0-19 to effectively meet the needs of the pediatric population.
Influencing the pipeline of behavioral health care providers such as social workers, nurses, psychologists and community navigators is a long-term effort, but children’s hospitals are looking at where they can access more workers in the short term. One field on the list: teaching.
It takes about four years to become a teacher, during which future educators complete a bachelor’s degree and teaching certification exam. There’s one gap in training, however. “Teachers come out of school prepared to teach, but a lot of their time is actually spent on behavioral management in the classroom,” Wilmoth says. “They’re not always prepared for that.”
Wilmoth says this gap is an opportunity for children’s hospitals, and Akron Children’s developed a teacher training program, which is philanthropically funded, to boost these skills.
Through a series of opportunities, teachers learn trauma-informed strategies for managing classroom challenges, such as student withdrawal and disengagement, class work aversion, verbal and physical aggression, hyperactivity and social isolation. Where teachers start in the program is dependent on school culture. “It depends on where the school is in their adoption so we may need to start with awareness,” Wilmoth says.
Akron Children’s presents school districts with a menu of options to personalize the training. After completing basic training, other continuing education opportunities include in-classroom consultations, lectures and small group coaching.
There are opportunities for a certified trauma and resilience practitioner to join the classroom to observe and collaborate with teachers to demonstrate how different strategies can help them manage classroom behavior.
“To be able to enhance teachers’ levels of confidence in behavioral management of the classroom can reduce their stress and lead to teacher retention,” says Doug Straight, clinical operations director, Psychiatry and Psychology at Akron Children’s. “A healthy workforce leads to healthy outcomes for children.”
But working with teachers isn’t the only area of opportunity. Liaw sees a potential pipeline of workers in the dwindling workforce outside of health care—professionals who have left their roles after the last two years and are trying to figure out what to do next.
“What if we built a mental health service corps?” Liaw proposed. “What if we took veterans, teachers, police officers and coaches and trained them in evidence-based practices for early identification, screening and triage referrals? Let them speak with families about mental health issues and stigma. There are many people we could be tapping into.”
'There are barriers including transportation, insurance, a limited number of specifically trained behavioral health providers. But once patients can get treatment, we have it, and it helps.'
Technology aids communication
Communication between providers, families and patients is critically important to delivering behavioral health care, and technology can make efforts even more effective. For example, children and families could find themselves in an emergency department that is not equipped to care for children, and the providers may be unsure of how to manage a child or teen in a mental health crisis.
Akron Children’s is examining how to use telehealth to support these providers. “We’re considering using virtual consultations and providing an assessment to determine whether youths need to come to Akron Children’s for admission or if they could be referred to local services within the community,” Straight says.
At UMCH, a newly built behavioral health inpatient unit and its creative design introduced new technology for care teams, changing how they communicate with each other and with families. The unit opened in summer 2021, and Edwards says it’s the first in Maryland to be designed both architecturally and programmatically to deliver trauma-informed care.
With no nursing station, the goal is to maximize staff interactions with patients and eliminate multitasking. “Patients shouldn’t have to know about how many notes you need to capture or that there’s a phone call or someone is trying to get in touch with you,” Edwards said. “They should be able to see that you’re fully there for them at that time.”
When nurses need to focus on administrative tasks, they leave the patient care area and settle in work rooms that are set up for phone calls, documentation needs and other tasks. The inspiration came from Disney’s live shows and characters who are always in character when they are around a guest. When nurses are “onstage,” they’re fully present with patients. When nurses are “offstage,” they’re able to shift and accomplish other tasks.
Edwards says this new design emphasized the importance of technology. “Because we don’t have a nurse’s station, we had to figure out how to best communicate,” she says. “We have cell phones with secure text messaging, but we have to learn how to do that at the right time. And there have been learning curves with using the different laptops and handheld devices.”
Refining a system
COVID-19 and its effects have played an important role in bringing to the forefront the conversation among health care leaders, legislators, communities and individual households about improving the pediatric behavioral health system.
The last two years have amplified the need and highlighted the vulnerabilities of the current system. At its core, this is a system issue. For Edwards, the good news is once kids find care, the right strategies and evidence-based practices are in place to help.
“We have good mental health treatment for youth, and it works,” says Edwards. “The systems can make it challenging to find that treatment. There are barriers including transportation, insurance, a limited number of specifically trained behavioral health providers. But once patients can get treatment, we have it, and it helps.”
