Children’s 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 size of the population, a problem that was growing before the pandemic has become a bigger problem.

“It’s the perfect storm,” said Sandy Mueller, executive director of Kootenai Health’s behavioral health services.

Even when families are able to connect their child with pediatric mental health services, they face paying $150-200 per week out of pocket for care for a one-hour session because most insurance companies, including Idaho Medicaid, do not reimburse good.

“It created a disparity between the haves and the have-nots,” Mueller said.

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

For families who cannot afford to pay out of pocket, pediatricians are the last line of defense and often lack the specialized training that mental health professionals would offer. The sooner pediatricians and families can flag mental health crises, the sooner children can be connected to care.

“We can make a huge impact by supporting pediatricians. When it comes to mental health, we tend to wait and see. We need to ring the bell earlier to get resources. It has to be very community-based,” Mueller said.

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

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

“Challenge is probably an understatement. We’ve had problems for the past 10 years, but they’ve gotten worse since COVID-19. In the medical field, we are struggling because our insurers are not paying or reimbursing and making it difficult to provide care,” Craduck said.

Accessing the necessary behavioral health resources for children with disabilities such as autism can be extremely difficult to navigate, and families can quickly become discouraged as they figure out all the steps that make up the process.

“Everyone 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 get access, and it can be a nine to 12 month wait to get a comprehensive neurological test done,” Craddock said.

Craddock sees the current situation as requiring a serious call to action from both health care providers and the state to begin creating infrastructure to counter the current gaps in mental and behavioral health coverage.

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

Children in crisis

What worries Mueller most about the crisis in pediatric health care is that children and young adults facing suicidal thoughts have few options outside of the pediatrician’s office.

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

There must be vehicles to help young people struggling with their mental health. The ratio of school counselors or mental health professionals in school districts could also use increased numbers to expand the mental health safety net and better gauge the emotional well-being of children in North Idaho.

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

When she was involved with San Diego Behavioral Health Urgent Care, the workers worked as part of an integrated behavioral health team. This practice involves blending care in one setting for both medical conditions and behavioral health factors in a more holistic approach.

“There’s a little bit of it here, but there’s a huge demand,” Mueller said.

Laying the groundwork for more intensive outpatient programs for child patients beyond mere medical management would help keep a better pulse on the tide of problems children face. One way medical and mental health professionals can begin to address the problem is by cultivating a network of local, state, and federal resources for pediatric behavioral health care.

“A current list of resources would mean more tools in their distribution toolbox. It takes time from the pediatrician to dig and look for everything,” Mueller said.

“It’s just a system failure”

Of the young patients he sees at Coeur d’Alene Pediatrics, Craddock said there has been an increase in mental health issues and the severity of the problems has also gone up.

“It’s not unusual to wait three to six months to see a consultant. Before that, our system couldn’t handle it, so it’s just a system failure,” 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. There aren’t many available in the state, and families have had to go all the way to North Carolina, Colorado or Wyoming. Not good by any means,” Craddock said.

The physical distance makes it difficult 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, mental health telehealth services are a lifesaver, but especially for moody teens. However, Craddock worries that video sessions can remove body language indicators that can tell more of the whole story about what’s troubling a child.

“If you get a one-word answer, it’s often not ‘okay’ or ‘ok’ or ‘okay.’ Let’s dig a little deeper,” Craduck said.

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

“It’s traditionally out of range and it’s more than what I’ve trained for,” Craddock said. “Primary care is what really struggles. You will completely burn out all your primary care doctors. We want more when they feel they have less.

Fewer clinicians and more demand

The mental and behavioral health workforce has changed during Mueller’s time in the field. She cites a combination of reasons behind having fewer mainstream providers.

When the pandemic hit, like many areas of health care, there was also a mass exodus from the field as burnout among mental health providers increased. Of those who 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 disincentives. Low pay also plagues mental and behavioral health clinicians.

“Interest rates haven’t gone up in 15 years,” Mueller said.

Weathering the storm

The best way to try to overcome the current crisis is to implement advocacy for children everywhere. Families, schools, doctors and government agencies must turn their attention to plugging some of the existing holes in the system.

“People need to recognize that there is a storm when we talk about mental health. People think that children 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 have to weather the storm,” Mueller said.

Mental Health Access Line

As another potential lifeline for Idaho’s pediatric mental health needs, Kootenai Health has sent a letter to the Idaho Medicaid office asking for the implementation of an access line to connect doctors with child mental and behavioral health experts.

“It would help the state of Idaho, not just the doctors. There are currently no child psychiatrists that you can call to access. Hopefully that will be in the future for Idaho. The challenge is that it requires a state agency to join and the state has to put 20 percent of the money into it,” Craduck 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 introduce a child mental health hotline for pediatric care providers to receive a direct consultation about a problem.

“Idaho doesn’t have a program yet, and federal grants require an agency and 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 as well, but you can’t wait for a supplier to come along,” Hilt said.

The Access Line operates as a hotline Monday through Friday that all primary care physicians in Washington can call when they have a child’s mental health question and connect with a child psychiatrist.

“We managed to do a lot. It is quite widely used and as it is an optional consultation line we get quite a few notices from some providers. We never receive information from some suppliers. It’s entirely up to them if they want to reach out and get some help,” Hilt said.

Thanks to this resource, many clinicians have been able to increase their ability to maintain the line when it comes to children’s mental health needs, and consultant psychiatrists on the patient access line have seen improvements in skills and patient outcomes over time.

“It’s actually in line with the principles of medical education that if a doctor goes to a lecture to learn something, that’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 keep it and pass it on to the next patient,” Hilt said.


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