Kids' mental health care faces 'perfect storm'

COEUR d’ALENE — Idaho is facing a crisis. With a lack of mental and behavioral health providers for children that reflects the population size, a problem growing prior to the pandemic has snowballed into a larger problem.

“It’s the perfect storm,” Sandy Mueller, Kootenai Health’s Executive Director of Behavioral Health Services said.

Even when families are able to connect their child to pediatric mental health services, they are faced with paying $150-200 per week out of pocket for care for an hour session because most insurance companies, including Idaho Medicaid, don’t reimburse well.

“It’s created a disparity with the have and have-nots,” Mueller said.

Early intervention is key, but it can often take six months for pediatric patients to be seen for complex conditions such as severe depression, anxiety, psychosis or bipolar disorder.

For families who can’t afford to pay out of pocket, pediatricians represent the last line of defense, and they often lack the specialized training that mental health professionals would bring to the table. The earlier pediatricians and families can flag mental health crises, the faster children can get connected to care.

“We can have a huge impact by supporting the pediatricians. In mental health, we tend to wait and see. We need to ring the bell sooner to get resources. It needs to be very community-based,” Mueller said.

The more that mental health care providers and pediatricians can do to provide individualized care with shared responsibility, the more that can be done for children in the long term.

Dr. Duane Craddock of Coeur d’Alene Pediatrics said that generally speaking, access to mental health counselors and social workers for child patients in need has gotten more difficult.

“Challenging is probably an understatement. We’ve had problems for the last 10 years, but it’s gotten worse since COVID-19. In the medical field, we struggle because our insurers don’t pay and they don’t reimburse and they’re making it more difficult to provide care,” Craddock said.

Access to necessary behavioral health resources for children with disabilities such as autism can be extremely difficult to navigate and families can quickly get discouraged figuring out all the steps that make up the process.

“Everybody is so surprised that it’s so hard to get in to see a provider. There are no child psychiatrists that you can call to have access to and it can take a nine to 12 months wait to get a comprehensive neuro test done,” Craddock said.

Craddock sees the current situation as requiring a major call to action by both health care providers and the state to start putting infrastructure in place to counter the current gaps in mental and behavioral health coverage.

“Recruit more psychologists with testing. Add services that will be helpful for crisis management. If you get support, you can be successful,” Craddock said.

Kids in crisis

What worries Mueller most about the pediatric health care crisis is that kids and young adults facing suicidal ideation have few options outside a pediatrician’s office.

“It’s a failed detection and a failed system of support,” Mueller said.

There need to be vehicles in place to help flag youth who are struggling with their mental health. The ratio of school counselors or mental health professionals in school districts could also use bolstered numbers to widen the mental health safety net and better gauge the emotional well-being of children in North Idaho.

“Nationally, there’s been a huge uptick in behavioral health needs for children, and we don’t necessarily have places to refer them to,” Mueller said.

When she was involved in behavioral health urgent care in San Diego, workers operated as part of an integrated behavioral health team. This practice entails blending care in one setting for both medical conditions and behavioral health factors in more of a holistic approach.

“There is some of that here, but there is a huge demand,” Mueller said.

Laying the groundwork for more intensive outpatient programs for child patients outside of just medical management would help better keep a pulse on a barrage of problems children are facing. One way medical and mental health professionals could start chipping away at the issue is by cultivating a network of local, state, and federal resources for pediatric behavioral health care.

“A current resource list would mean more tools in their toolbox to distribute. It takes time from the pediatrician to dig and go looking for it all,” Mueller said.

‘It’s just a failure of the system’

Of the young patients he sees at Coeur d’Alene pediatrics, Craddock said there is an increase in mental health issues, and the severity of issues has also climbed.

“It’s not uncommon to have a three to six-month wait to see a counselor. Our system wasn’t keeping up previously, so it’s just a failure of the system,” he said.

“When it comes to residential care, we’ve had to have kids go out of state for residential care, which is extremely expensive. Not much available in the state, and families have had to go as far away as North Carolina, Colorado or Wyoming. It’s not good any way around,” Craddock said.

The physical distance makes it hard for families to check in with them in person because they have to travel to see them.

For young patients in need of mental health services, telehealth mental health services are a lifeline, but especially for brooding teenagers. Craddock worries though, that video sessions can remove body language indicators that can tell more of the whole story of what is troubling a child.

“If you get a one-word answer, often this is not ‘fine’ or ‘OK’ or ‘good.’ Let’s dig a little deeper,” Craddock said.

Pediatricians are feeling the burden the lack of behavioral health providers has caused and many of them, like Craddock, are going through more mental health training to fill the void.

“It’s traditionally beyond the scope and is more than what I trained for,” Craddock said. “Primary care is what’s really struggling. You’re going to totally burn out all of your primary care physicians. We’re asking for more when they feel like they have less.”

Fewer clinicians and higher demand

The mental and behavioral health workforce has changed in the time that Mueller has been in the field. She cites a combination of causes behind there being fewer mainstream providers.

When the pandemic hit, like many health care fields, there was also a mass exodus from the field as burnout among mental health providers increased. Of those that remained in the field, many turned to private practice instead of clinical work. Clinical work requires eight years in the field before mental health providers can work independently, which creates time-related deterrents. A low rate of pay also plagues clinicians in the mental and behavioral health fields.

“The rates have not had an increase in 15 years,” Mueller said.

Weathering the storm

The best way to try and get through the current crisis is to implement advocacy across the board for children. Families, schools, doctors and governmental agencies need to direct their attention to plugging up some of the existing holes in the system.

“People need to recognize there is a storm when we’re talking about mental health. People think kiddos have more resilience than they do. Maybe our legislature can help us go after the insurance companies,” Mueller said.

More people are needed to speak up and fight for better access to testing, community support and additional resources.

“We need to weather the storm,” Mueller said.

Mental health access line

As another potential lifeline for pediatric mental health needs in Idaho, Kootenai Health has sent a letter to the Idaho Medicaid office to ask to implement an access line that would connect medical doctors to child mental and behavioral health experts.

“This would help the state of Idaho, not just physicians. There are currently no child psychiatrists that you can call to have access to. We would hope that it would be in the future for Idaho. The challenge is, it requires a state agency to sign on and the state has to put 20% of the money into it,” Craddock said.

Robert Hilt is the founder and creator of the Patient Access Line and works at Seattle Children’s Hospital. Washington state was the second state to implement a child mental health helpline for pediatric care providers to get direct consultation on an issue.

“Idaho doesn’t have a program yet and federal grants require an agency and have boots on the ground. They also require state funding. It’s very possible to create access lines and we’ve created them in Wyoming and Alaska, too, but you can’t wait for a provider to appear,” Hilt said.

The access line works as a Monday-to-Friday hotline that all primary care physicians in Washington can call whenever they have a child mental health question and reach a child psychiatrist.

“We’ve been able to do quite a bit. It’s been pretty extensively utilized and being an elective consult line, we hear from some providers quite a lot. Some providers, we never hear from. It’s entirely up to them if they want to reach out and get some help,” Hilt said.

Because of this resource, many doctors have been able to add to their capability in holding the line when it comes to child mental health needs and consulting psychiatrists at the Patient Access Line have seen improvements in patient skills and outcomes over time.

“It actually fits with medical education principles that if a doctor goes to a lecture to learn about something, it’s not the best way to learn, but when it’s your patient and you’re going to learn how to do something for your patient, it’s a teachable moment. They can retain it and pass it along to the next patient,” Hilt said.