Addressing the Pediatric Mental Health Crisis: Moving from a Reactive to a Proactive System of Care

Over the last several decades, there have been global increases in youth impacted by mental health disorders.1Kyu H.H. Pinho C. Wagner J.A. Brown J.C. Bertozzi-Villa A. Charlson F.J. et al.Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: findings from the global burden of disease 2013 study.JAMA Pediatr. 2016; 170: 267-287Crossref PubMed Scopus (413) Google Scholar Our nation has experienced similar surges that have outstripped our abilities to provide care.2Cummings J.R. Wen H. Druss B.G. Improving access to mental health services for youth in the United States.JAMA. 2013; 309: 553-554Crossref PubMed Scopus (70) Google Scholar,3Services CfMHNational survey of mental health treatment facilities. Substance Abuse and Mental Health Services Administration, Rockville, MD2008Google Scholar Before the coronavirus disease 2019 pandemic, there was a dramatic escalation in mood disorders and suicidal behavior in adolescents.4Twenge J.M. Cooper A.B. Joiner T.E. Duffy M.E. Binau S.G. Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005–2017.J Abnorm Psychol. 2019; 128: 185Crossref PubMed Scopus (549) Google Scholar,5Mojtabai R. Olfson M. Han B. National trends in the prevalence and treatment of depression in adolescents and young adults.Pediatrics. 2016; 138e20161878Crossref PubMed Scopus (785) Google Scholar Pediatric emergency departments (EDs) were overwhelmed by urgent mental health visits,6Lo C.B. Bridge J.A. Shi J. Ludwig L. Stanley R.M. Children's mental health emergency department visits: 2007–2016.Pediatrics. 2020; 145e20191536Crossref Scopus (72) Google Scholar with an apparent increase in severity of illness.7Cushing A.M. Liberman D.B. Pham P.K. Michelson K.A. Festekjian A. Chang T.P. et al.Mental health Revisits at US pediatric emergency departments.JAMA Pediatr. 2023; 177: 168-176Crossref Scopus (3) Google Scholar The impact of the coronavirus disease 2019 pandemic has inflamed this crisis with further dramatic increases in youth suffering from anxiety and depression.8Racine N. McArthur B.A. Cooke J.E. Eirich R. Zhu J. Madigan S. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis.JAMA Pediatr. 2021; 175: 1142-1150Crossref PubMed Scopus (603) Google Scholar At the same time, mental health ED visits continue to increase with more severe symptoms and the need for hospitalization.9Krass P. Dalton E. Doupnik S.K. Esposito J. US pediatric emergency department visits for mental health conditions during the COVID-19 pandemic.JAMA Netw Open. 2021; 4: e218533Crossref PubMed Scopus (68) Google Scholar The recent declaration of a national emergency in child and adolescent mental health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association has called on the entire healthcare system to address the explosion in unmet youth mental health needs.10Pediatrics AAoAAP-AACAP-CHA declaration of a national emergency in child and adolescent mental health. American Academy of Pediatrics, Illinois2021Google Scholar The local experience in Southern Ohio has mirrored the national experience. From 2011 through 2017, the number of children and adolescents presenting to our pediatric emergency services in mental health crisis doubled (Figure 1), with crisis identified as presentation to the ED for a mental health assessment due to concerns for safety to self or others. For many years, Cincinnati Children's Hospital Medical Center (CCHMC) has been reactively expanding services to meet this need, including the building of a 130-bed inpatient and residential psychiatric hospital. Between 2014 and 2017, we grew outpatient services focused on providing evidence-based care and school-based services and saw 44% more patients (Figure 2). The community response to offering such services led to further identification of the hospital as the central point for access to mental health services for the region bringing in ever-increasing numbers of referrals and patients in emerging crises. Despite significant growth in treatment facilities year over year, patients waiting for care or overflowing to medical services did not abate.Figure 2Mental health outpatient visits by fiscal year.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In 2018, CCHMC formed the Mind Brain Behavior Collaborative to move from a reactive approach to treatment needs to a more proactive integrated system of care. This article describes this proactive approach to address gaps in the mental health ecosystem along with complementary innovative upstream research and clinical care efforts. First, we developed a vision of the behavioral health care continuum that gave all stakeholders a shared understanding, a common language, and facilitated identification of gaps in our system of care (Figure 3). Foremost among these gaps was the needed development of services to manage children and families in crisis who exceeded outpatient care capabilities but were not appropriate for inpatient admission (level 3, Figure 3). Second was the engagement in prevention efforts to bend the curve so that over time, less-intensive services would be needed (level 1, Figure 3). Third, there had to be a focus on the earlier identification of illness with intervention to mitigate the course of illness and the need for intensive services (level 1, Figure 3). We built 4 additional resources in levels 1 and 3: a Project ECHO (Extension for Community Healthcare Outcomes) program for enhancing pediatrician understanding and management skills for basic mental health issues, integrated behavioral health (IBH) into primary care practices with psychologists embedded in pediatrics offices, and developed both a Bridge clinic and Intensive Outpatient Programming (IOP, 2-3 times/week). Our institution recognized the importance of partnering with community providers to increase knowledge and self-efficacy around the management of mental and behavioral health conditions. The Project ECHO model11Zhou C. Crawford A. Serhal E. Kurdyak P. Sockalingam S. The impact of project. ECHO on participant and patient outcomes: a Systematic Review.Acad Med. 2016; 91: 1439-1461Crossref PubMed Scopus (0) Google Scholar was selected to advance the education and support of community providers, who are the first line for identifying and treating mental and behavioral health conditions. Specifically, Project ECHO links expert specialists (psychiatrists and psychologists) with community providers via a virtual platform to develop providers' skills and knowledge to treat patients within their practices. Our Project ECHO courses have taken a multidisciplinary approach to provider education. We have spread the program offerings to include courses geared not just for primary care providers but also for master's level community mental health therapists and school personnel. The Project ECHO program has grown significantly in the past 5 years with donor funding (Maxon Foundation) supporting these efforts, and plans include additional growth with an increased focus on clinical and population health outcomes. To date, we have expanded the program to include 5 mental health–focused courses targeting topics of depression, anxiety, an advanced diagnostic and medication management training for primary care providers, and 2 courses for mental health therapists targeting the treatment of complex cases. Most recently, we began a trauma course open to a variety of providers working with youth (eg, pediatricians, therapists, and school personnel). Nineteen cohorts have completed these courses, which include 258 unique learners, with 47 participants taking multiple courses. Participants represent 153 different primary care practices and behavioral health organizations. Initially, we tested a prevention and early intervention model within the primary care clinics of our academic medical center.12Herbst R.B. McClure J.M. Ammerman R.T. Stark L.J. Kahn R.S. Mansour M.E. et al.Four innovations: a robust integrated behavioral health program in pediatric. primary care.Fam Syst Health. 2020; 38: 450-463Crossref PubMed Scopus (0) Google Scholar Similar to our robust model of integrating psychologists into medical subspeciality clinics (eg, cystic fibrosis, headache, epilepsy), psychologists were embedded in primary care clinics. However, for IBH, the goal of the prevention model focused on promoting optimal infant and child psychosocial development by being part of all well-child visits for patients ages 0-5 years and by providing evidence-based intervention strategies for common child development concerns, including responding to crying, infant calming, irritability, toddler behavioral problems, sleep, and feeding concerns. In the initial pilot involving 2 psychologists in 1 primary care site, 863 families were seen, and 92% reported using all or some of the interventions taught to them by the psychologist, with 77% reporting improvement in their child's behavioral concerns after only 1 visit.13Ammerman R.T. Herbst R. Stark L.J. Integrated behavioral health prevention in pediatric primary care. Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio2021Google Scholar This service line expanded beyond prevention to early intervention when a child of any age presenting to the clinic with behavioral or mental health concerns was seen for a real-time "warm-hand off" with a psychologist who provided a brief assessment and intervention, as well as offered follow-up colocated appointments as needed. To assess satisfaction with IBH services, caregivers received 2 survey questions by text after their visit asking them to use a scale of 1 “strongly disagree” to 5 “strongly agree” to rate their experience on 2 questions: “I feel clearer about the things I can do to support my child to be the healthiest they can be” and “I felt valued by this provider.” During the time of the survey, 472 caregivers responded with a mean score of 4.8 on both questions.13Ammerman R.T. Herbst R. Stark L.J. Integrated behavioral health prevention in pediatric primary care. Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio2021Google Scholar We extended this prevention and early intervention model to our 2 other sites of care. Over time, we expanded to include addressing acute mental health concerns, including suicidal intent within primary care to prevent unnecessary emergency room visits. We have grown from 2 to 12 IBH psychologists covering 3 primary care clinic locations and established that it could be effective (as measured by caregiver report of interventions used and improvement seen in child behavior). Given the increased access to behavioral health services this model has demonstrated, we also partnered with community primary care practices to embed master's level therapists with psychologist supervision in 10 community practices to date. This model has been self-sustaining as revenue has covered the cost of salaries, fringe, and overhead of the services. By 2014, we had developed and implemented a Psychiatric Intake Response Center, a 24-hour, 7-day a week program that performed emergency assessments, phone consultation, and triage of patients in acute crisis to match patients to the appropriate level of care between outpatient and inpatient care by psychiatric social workers. This team also served as the psychiatric consultation to the ED, with psychiatric social workers conducting assessments to determine the disposition of youth presenting to the ED with mental health concerns under the supervision of psychiatrists. To expand crisis service options beyond an inpatient vs outpatient dichotomy, we created a Bridge service along with Intensive Outpatient Therapy Services. The Bridge service allowed us to safely divert those patients in crisis, but not acutely suicidal, from going to the ED to an outpatient clinic where they could be seen immediately for assessment, intervention, and short-term follow-up until they could be transferred to an outpatient appointment, our intensive outpatient program, or partial hospital services. Bridge appointments were also offered to patients presenting to the ED for immediate next-day follow-up, thereby allowing us to discharge safely those patients who require faster access than their outpatient therapist could provide or until an outpatient therapist could be identified and scheduled (for patients without prior outpatient care). Bridge volumes have doubled over the past 2 years with 2394 bridge crisis appointments in fiscal year 2022. The Bridge program is self-sustaining via the use of outpatient billing codes for psychiatric social workers as providers of care. Due to the success of this Bridge model, the service was expanded and embedded within primary care by training the IBH providers in the same assessment used in Bridge and the ED. Patients could be referred to or seen through warm handoffs in primary care clinics and receive these Bridge assessments, as well as same-day and follow-up interventions for stabilization of symptoms. The initial pilot of Bridge with the academic medical center's primary care IBH providers resulted in 31 patients being evaluated in the primary care clinic rather than the ED, and 28 of those 31 were safely discharged home and managed through outpatient care. The other 3 were determined to need inpatient treatment to maintain safety and were able to be directly admitted to inpatient psychiatric units without going to the ED. This crisis management and intervention model was then spread to our community-based IBH services and demonstrated similar results. Specifically, in fiscal year 2022, 101 youth received crisis assessments and interventions by the IBH provider within their community primary care provider practices rather than the ED, and 95 of those patients were safely discharged home. Our IOP (Figure 3, level 3) was implemented to prevent unnecessary ED visits and inpatient admissions for patients experiencing a crisis or rising risk factors. IOP is an alternative to ED crisis management by providing effective and intensive evidence-based interventions and safety and symptom monitoring several times a week on an outpatient basis. This level of intensive intervention and symptom monitoring provides a safe discharge from ED for youth who need more than traditional outpatient services but can be maintained safely in the home and community with this level of support, and thus avoid an inpatient hospitalization. The IOP program may also receive referrals from an outpatient therapist when a child and family is in crisis, experiencing an exacerbation of symptoms, and needing more frequent and intensive interventions than an outpatient therapist can accommodate in their schedule. The patient can be seen 2 to 3 times a week over several weeks to manage the acute crisis, reduce symptom severity and frequency, and then safely transition back to weekly therapy with their outpatient therapist. IOP referrals can thus come from Psychiatric Intake Response Center triage, the ED or inpatient treatment teams, or outpatient therapists. With this intensive treatment approach, the average length of treatment for our IOP services has been 4 weeks, providing access to care for a higher number of patients per year compared with a traditional outpatient model (averaging 3 months of treatment per patient). IOP providers, on average, can treat ∼150 unique patients per year compared with traditional outpatient providers who can treat ∼ 100 per year. This treatment model was launched with philanthropic support from the Convalescent Hospital Fund for Children and continues to receive supplementation. Of the 523 unique patients served in IOP only 0.2% (1 patient) and 1% (6 patients) had emergency room visits within 7 days and 30 days of completing IOP treatment, respectively. As we look toward the future, we are focused on developing innovations that operate upstream (levels 1 and 2) in our care system. The goals are to reach more youth earlier and better integrate with our community partners through pioneering prevention and early identification programs while delivering standardized, evidence-based treatments. We are focused on 4 novel approaches to achieve these goals. First, based on the premise that early identification, prevention, and early intervention optimize outcomes in mental and behavioral health disorders, in 2020, CCHMC made an institutional strategic investment in a project called the Mental Health Trajectory project focused on creating real-time pediatric trajectories for early identification of anxiety, depression, and suicidality. The project's deliverables are patient-specific mental and behavioral health trajectory plots that, like traditional growth charts, can be used by primary care providers and community agencies to identify normally appearing children who are on a near term path to develop clinically significant anxiety, depression, or suicidality. These patient-specific trajectories are developed using novel proprietary natural language processing and artificial intelligence techniques within a high-performance computing environment provided by our exclusive supercomputer partner at Oak Ridge National Laboratories (https://www.ornl.gov/). Once these computational mental health models are validated, we plan to implement them into routine clinical practice and identify factors that could be targeted for prevention interventions. This Mental Health Trajectory project's ambitious goals are to implement this real-time integrated "early warning" computational system for anxiety and depression in young children across our health care ecosystem. A blue sky goal is to use the system to eliminate pediatric suicides in our region by 2033. To date, the Mental Health Trajectory project has developed and validated subject matter expert computational models of anxiety, created a foundational data set of the 1.3 million unique patient records from CCHMC electronic health record, identified and integrated census, social determinants of health, environmental, and other population-based external data into the data set, implemented geocoding of integrated data, developed data reliability, validity, and quality algorithms, and performed anxiety feature selection. We have developed anxiety pilot models that correctly identify normal-appearing patients destined to be diagnosed with clinical anxiety within the next 50 days. We plan, over the next 3 years, to validate this early warning anxiety algorithm, design a practical, clinically useable, and testable early warning anxiety software system, perform clinical testing, and have primary care clinicians readily incorporate this system into their practice that along with the spread of IBH care will allow us to offer evidence-based prevention strategies to patients and their families. Second, while this early warning anxiety algorithm is being developed and implemented, a parallel current effort is underway to implement standardized screening. Specifically, much work has been done on standardizing depression screening using the PHQ-9, treatment algorithms for depression, and safety assessments using the Columbia Suicide Severity Rating Scale, both within our academic medical center as well as with our community partners in our clinically integrated network. This work has followed a quality improvement approach and has included educational initiatives and process measures of implementation of screening, leading to reliably high screening rates across our network (>95%). Future enhancement of this work will include testing more sensitive assessment measures of suicide risk such as the Ask Suicide-Screening Questions14Horowitz L.M. Bridge J.A. Teach S.J. Ballard E. Klima J. Rosenstein D.L. Pao M. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department.Arch Pediatr Adolesc Med. 2012; 166: 1170-1176Crossref PubMed Scopus (245) Google Scholar,15Horowitz L.M. Snyder D.J. Boudreaux E.D. He J.P. Harrington C.J. Cai J. et al.Validation of the ask suicide-screening questions (ASQ) for adult medical inpatients: a brief tool for all ages.Psychosomatics. 2020; 61: 713-722Crossref PubMed Scopus (0) Google Scholar and then, if positive, follow-up with the Columbia Suicide Severity Rating Scale. We will also use continuous quality improvement methodology to expand the focus from process measures to include patient outcome measures and further spread effective clinical interventions by medical and mental health providers. Third, CCHMC has prioritized both population health and mental health as key pillars in our long-term strategic plan. With an increased focus on population health, we can expand the impact of our comprehensive mental health care system in the coming years through strong community partnerships and collaborations. Through the 2021 launch of an accountable care organization, CCHMC HealthVine, we have prioritized improving youths' lives through an IBH approach to care, with recognition of the bidirectional impact of physical and behavioral health initiatives in improving the lives of all children. Recognizing the return on investment, HealthVine has begun supporting the continued expansion of the direct service lines included in the mental health system of care outlined above along with the advancement of population behavioral health, including increasing support for youth and families outside of traditional mental health treatment. Care coordination has been significantly expanded through HealthVine, explicitly addressing social determinants of health and barriers families face to thriving so that children can reach their full potential. HealthVine care coordinators and community health workers partner with families, providers, schools, and other community resources to wrap services and support around youth with physical and/or behavioral health needs (eg, resolving transportation barriers, housing challenges, and connecting youth to clubs or sports teams). Consistent with our integrated and holistic approach to care, the HealthVine care coordination team receives universal training and access to daily consultation in behavioral health topics from a clinical pediatric psychologist and weekly consultation with a child and adolescent psychiatrist, regardless of whether the youth they serve are receiving care coordination due to primarily physical or behavioral health concerns. Trainings include topics such as key components of evidenced based mental health treatment, trauma informed approaches to working with families, motivational interviewing skill development and application, and building knowledge and skills around diversity, equity, inclusion, and health equity. One barrier to fully coordinated and integrated care for youth is that, historically, there has been limited transparency of data or information across the physical and mental health systems of care. The first step in improving this for the future is sharing basic clinical information and data to eventually have more population-level programs for measuring and tracking patient outcomes. HealthVine has led advancements in reducing silos and increasing access to such information by granting CCHMC's electronic health record access to community behavioral health providers. In contrast, historically, only physical health providers had access. This expansion has increased transparency and collaboration across our system. In addition, HealthVine has partnered with community behavioral health organizations and the health information exchange to share weekly data on patient panels and include information on the care teams in the hospital's electronic health record so that anyone with access to the system (eg, internal and community physical health and behavioral health providers) can see where the youth they are caring for is receiving physical and behavioral health care. Organization-level dashboards have been created to guide population health work by providing real-time access to various metrics, including numbers and lists of youth enrolled in care coordination services, youth with rising risk of ED visit, youth prescribed 2 or more antipsychotics, and youth currently admitted to the ED for behavioral health or to our inpatient psychiatric hospital. These data will facilitate the coordination of care between the community behavioral health organizations and the hospital, allowing for the adjustment of support and resources for families as their needs change. Having visibility into these organization-level metrics across our region (eg, ED rates by the organization, number of youth with rising risk by the organization) will guide future quality improvement work at the population level by helping to identify areas that are experiencing success along with opportunities for improvement through spreading successful initiatives. Dashboards could also support measurement and improvement efforts around metrics such as boarding, psychiatric readmission rates, and death by suicide. Finally, we recognize the importance of partnering with caregivers and community providers to increase knowledge and self-efficacy around the management of mental and behavioral health conditions. We are developing a community-wide Learning Health Network to promote service linkage, data sharing, evidence-based practice, quality improvement, and innovation. The use of upstream technology for early identification and prevention through the Mental Health Trajectories program will play an important role in reducing the downstream overwhelming volume of mental and behavioral disorders both in pediatrics and ultimately in adults. The Project ECHO model was selected as one way to advance the education and support of community providers, who are the first line for identifying and treating mental and behavioral health conditions. Our Project ECHO courses have taken a multidisciplinary approach to provider education. We have spread the program offerings to include courses geared not just for primary care providers but also toward community mental health therapists and school personnel. The Project ECHO program has grown significantly in the past 5 years, and plans include additional growth with an increased focus on evidence-based practices and clinical and population health outcomes. We realize that our model may not directly apply or solve all the challenges in every community, and that 2 of these initiatives (Project ECHO and IOP) require philanthropy which may not be available at other institutions. We also recognize that we cannot ascribe the decrease in ED visits (Figure 1) directly to any single or bundle of interventions described in this paper given that we are reporting on clinical data and not a study designed to test the impact of the interventions. Still, we feel that by describing our journey, we can spark new conversations and novel collaborations across pediatric hospitals. We believe specific foundational principles embedded in our system will need to be incorporated into all future successful approaches. First, individual mental health care systems need to shift from reactive to proactive models that, while responding to the acute crisis, are built to strengthen and enhance upstream systems that will significantly reduce (and hopefully prevent) the need for crisis care in future generations. Second, these proactive models will require patient and family engagement and focused, planned investments in people, infrastructure, education, and advocacy to be successful. Third, health care organizations and payers must place behavioral and mental health care needs on equal footing with physical health care so that patients and their families receive comprehensive health care at every visit. Finally, we need to integrate artificial intelligence, machine learning, neural networks, and other technological advances to ethically push the boundaries of early identification and intervention so that children and teens get the care they deserve as early as possible. Together, we can develop a comprehensive health care system that helps every child reach their full potential. All authors conceptualized and drafted the manuscript and approved the final manuscript as submitted and agreed to be accountable for all aspects of the work. The authors declare no conflicts of interest.