With Pediatric Mental Health Facing a Crisis, Rady Children’s Leads the Way

You can’t solve a problem without understanding its roots. Band-aids and workarounds may offer temporary relief, but until you get to the heart of the matter, short-term fixes will only ensure that the problem persists.

The state of child and adolescent mental health in the US isn’t just a problem—it’s a crisis, and one with far-reaching and often tragic consequences.

• One in five youths aged 13 to 18 live with a serious mental illness.
• Suicide was the second-leading cause of death among 13- to 19-year-olds in 2019.
• 55% of US counties do not have a single practicing psychiatrist.^[1]

The pandemic has inspired a growing conversation about mental health care, especially as it concerns children. Hospitals saw double-digit increases in mental health emergency visits in 2020, and in 2021, several major pediatric organizations declared a national emergency in child and adolescent mental health.^[2]

But to view pediatric behavioral health solely through the lens of the pandemic is to miss the bigger picture. This problem has been years, if not decades, in the making.

• In 2016, half of US children with a treatable health disorder did not receive needed treatment from a mental health professional.^[3]
• From 2009 to 2019, more than one in three students reported persistent feelings of sadness or hopelessness.^[4]
• The years 2007 to 2018 saw suicide rates increase by 57% among youths aged 10 to 24.^[5]

If we think of the child mental health crisis as a pandemic-induced phenomenon, we run the risk of assuming the trouble will subside as our daily lives return to their familiar, pre-pandemic patterns. And lack of proper behavioral health care was an issue long before COVID-19 entered our lexicon.

Still, while the pandemic didn’t cause the problem, it may serve as a catalyst for solving it. Overwhelmed healthcare organizations have amplified their calls for change, and in December 2021, US Surgeon General Dr. Vivek Murthy issued an advisory highlighting the need to address the nation’s youth mental health crisis.

Attention isn’t the same as action, though, and when it comes to changing the way we deliver mental health care to children, the solution may be as complex as the problem. Meaningful change will take years and require a massive collective effort with communities, lawmakers, payers, providers, advocates, and philanthropists all rowing in the same direction. In a country that’s increasingly divided, that kind of collaboration is hard to fathom.

The good news? There’s already proof it can be done.

A Model for Pediatric Behavioral Health on the West Coast

Rady Children’s Hospital in San Diego, California, is the only hospital in the area dedicated exclusively to pediatric healthcare and the region’s only designated pediatric trauma center. The medical center is also home to one of the nation’s few psychiatric emergency departments for children.

Rady Children’s was better positioned than many healthcare organizations to respond to the rise in pediatric mental health admissions during the pandemic. That readiness didn’t happen overnight.

“We have been focusing on expanding our mental health footprint for over a decade now,” says Domonique Hensler, Senior Director of Care Redesign Delivery and Mental Health Integration at Rady Children’s. “We started with opening an inpatient child and adolescent psychiatry unit in 2012. At that time, we were starting to notice that there were visits to our emergency department with children in mental health crisis, but it was approximately 300 children a year. By about 2015, the number of children presenting to our ED increased by 500%.”

Sensing the start of an alarming trend, the leadership team approached the hospital board with a strategic plan for expanding their continuum of care for children with behavioral health diagnoses. The plan involved changes to behavioral health urgent care, expanded depression screening, and an increased focus on prevention and earlier detection of mental health issues. Central to this, Domonique says, was “focusing on the whole child and recognizing that there is no health without mental health.” The board listened, and in 2015 committed to expanding its mental health services.

A Unified Approach to Care

The concept that behavioral health and physical health are inextricably intertwined is a foundational philosophy that informs Rady Children’s’ approach to care. “If a child goes to see their PCP and they hear a murmur, we’re going to get an appointment with a cardiologist pretty quickly,” says Anne Bird, MD, Medical Program Director of Behavioral Health Integration at Rady Children’s. “You would never have a kid walking around with a potentially fatal heart disease when there was treatment they could get. So why is that allowed for behavioral health?”

With volumes continuing to increase, in 2019 Rady Children’s received a generous anonymous donation that was used to fund the Transforming Mental Health initiative, focused on promoting whole-child care and integrating mental health with pediatric primary care. “We go beyond the walls of the department to focus on behavioral health as an integrated delivery system,” Domonique says. “Any door you go into, whether it’s the hospital, a specialty clinic, or the primary care setting, we’re oriented on whole-child health, which includes a lens on mental health needs.”

Three Components of Success

Rady Children’s Hospital has benefited from years of investment in its behavioral health program, which is rare among pediatric institutions. Behavioral health has never been a revenue driver, payer reimbursement for mental health providers is historically anemic, and a fragmented market makes it difficult to build cohesive programs. But now hospitals are struggling to meet the skyrocketing demand for mental health services, and many organizations don’t even know where to begin.

“I think every community has to perform their own strategic planning process and assess their needs, but where to start can be an overwhelming question,” acknowledges Domonique.

But there are three topics that Domonique and Dr. Bird repeatedly return to when describing the growth and success of their program: leadership support, education, and integration. Regardless of how an organization’s behavioral health journey begins, these are likely to be the pillars of its success.

Leadership

It starts at the top. No behavioral health initiative will get far without hospital leaders who believe in the program and who are dedicated to its sustainability and success. And let’s be clear about what that means—they need to summon the financial and political wherewithal to develop a program that may lose money in the short term but will help drive down long-term medical expenditures and contribute to the provision of whole-person healthcare.

For hospitals operating with slim margins and still reeling from the upheaval of COVID-19, the thought of implementing a potentially loss-leading program is understandably a tough pill to swallow. But part of transforming the behavioral health space means redefining return on investment (ROI). Leadership needs to look beyond the short-term ROI of an individual program and consider the long-term benefits of building a healthier overall community. Today’s healthy kids are tomorrow’s healthy adults, and that’s good for the entire healthcare system.

Both Dr. Bird and Domonique are effusive about Rady Children’s’ commitment. “I credit our governance and senior leadership that they recognized the need to focus on the whole child,” Domonique says.

“I’ve been blown away by the leadership support,” Dr. Bird adds. “One of the things that really reassured me when I transitioned to Rady Children’s was the immense organization and leadership support and investment in an integrated care model for pediatrics. You need a true commitment from the organization, not just optically, but real, true investment in both changing the culture as well as the financial implications and strategic goals that go along with that.”

And while hospital buy-in is crucial, there’s a need for external leadership as well. Domonique explains that transforming mental health care will necessitate policy changes at the state and federal level to enact payment reform and establish standards of care, among other issues. She’s encouraged that California Governor Gavin Newsom appointed Nadine Burke Harris as the state’s first surgeon general in 2019, noting her extensive work in Adverse Childhood Experiences (ACEs). [Note: Harris resigned in February 2020.]

Education

Transforming mental health involves changing government healthcare policy, changing the way care is reimbursed, and changing the way we define return on investment. And providers need to change too.

“We’re having to retrain some of our staff to look at how can we do this effectively and efficiently with a performance improvement lens,” Domonique says. That extends to Rady Children’s’ affiliated primary care group, even though they’re a separate corporate entity. “They have gone through a process in partnership with Rady Children’s Hospital to train all of their primary care providers on signs and symptoms, how to identify and manage basic and common mental health conditions, and to work in partnership with psychiatry leadership as well as our mental health integration team on how to manage cases. They do it as a primary system, and together we work on it in an intentional way.”

Dr. Bird says that that approach to training has to occur on a national level. She’s board-certified as a pediatrician, a child psychiatrist, and an adult psychiatrist, and the interface between those disciplines enables her to understand her patients more holistically. “Pediatricians every day are seeing kids with behavioral health needs, and they really need additional training to have a comfort level to be able to take care of that population of patients,” she says. “Nationally, we need to have more of those types of training programs where integrated care is embedded into the way our clinicians think.”

The need for more education extends beyond the walls of the hospital. Domonique and Dr. Bird both emphasize the need to create better awareness about mental health and reduce the stigma associated with mental health treatment. “So much promotion work needs to happen,” Dr. Bird says, advocating for sweeping change in the form of “marketing campaigns, school curriculums, community awareness events, and really a community insisting that mental health assistance, guidance, and treatment is a human right that they should have.”

Integration

At the core of Rady Children’s’ Transforming Mental Health initiative is a care model in which behavioral health and primary care are integrated. As part of the program, an integrated health therapist (IHT), who is typically a licensed clinical social worker, family therapist, clinical counselor, or psychologist, is placed at a pediatrician’s office to respond to children’s mental health needs as identified through behavioral health screening.

The goal is to identify mental health issues as early as possible, and do so in an environment where children and their families are more apt to feel comfortable discussing sensitive topics. “We have an immediate referral and connection to care called a warm handoff, and it’s that doctor or primary care provider vouching for the therapist, which also helps with destigmatizing,” Domonique explains. “And it says to the patient, ‘there’s a person here who’s part of our team, and we really think that it would be great if you met each other and they could help you sort through some of these concerns that came up today.’ You’re empowering that patient and their family to be part of the decision and to buy in more.”

The integrated model Domonique describes sounds effective. But hearing her describe it in action is nothing short of powerful. In her words:

“We had an 11-year-old child come in for their annual checkup with their pediatrician, and our pediatrician had just been through the training on mental and behavioral health conditions and basic psychopharmacology. The child screened negative for depression, but the doctor was now a bit more oriented toward asking about mental health concerns. So they asked one more question, and the child became tearful. And it turns out, unbeknownst to the family, this child had been bullied online and was very anxious and was suffering.

“Immediately the pediatrician was able to ping our IHT to join the visit in the exam room. Within minutes, our IHT was there and was able to be introduced and take them back to the IHT office. The IHT then rescreened for depression as well as for anxiety and found this child’s anxiety was off the charts, and they had some depression. They were able to do some safety planning and give them some coping strategies that the child could work on and some tips that the family could work on together to help the child manage their anxious symptoms. The child was seen five time in less than 40 days at the PCP’s office—a true holistic medical home with our IHT. And their scores for anxiety were cut by over 53%.

“Compare that to care as usual, where you might wait up to six months for that first appointment in the community. For parents, it can be overwhelming to navigate the system. There’s a long wait list, or they may not understand if [the provider] is trained in what their child needs. We were able to significantly impact this child’s overall health and well-being within five visits in less than 40 days. That’s the power of our model.”

A Time for Leadership

It’s hard to hear a story like that and not wonder why there aren’t more integrated behavioral health–primary care models throughout the US. The answer is distressingly familiar.

“One of the biggest barriers for most institutions in terms of implementing an integrated care program is that insurers don’t adequately pay for the core components of that service,” Dr. Bird explains. “That speaks to the need for changes, for a federal investment in integrated care.” The inconsistent application of mental health parity continues to be an issue as well.

Change requires leadership. Ultimately it needs come from the federal level, but expecting a hyperpartisan Congress to suddenly become agents of change for pediatric behavioral health is a shaky strategy at best.

For Rady Children’s, leadership came from within. Support from the hospital’s board, regardless of the financial ROI, is what fostered the growth of a program that’s focused on integrated, whole-person care. It’s a comprehensive approach that’s making a difference in its community. That, in turn, makes Rady Children’s a leader, and it proves to the broader industry that while child and adolescent mental health care access is a vexing problem, solutions do exist.

Published May 17, 2022