AAP offers guidance for nonpharmacologic mental health care

The American Academy of Pediatrics (AAP) has released its first-ever guidance on nonpharmacologic management of mental health disorders in children.

The policy statement provides an overview of the challenges pediatricians face in offering interventions to children in an area where resources are so often limited.

Mary Margaret Gleason, MD, FAAP, is a pediatrician and child and adolescent psychologist, as well as the director for Tulane Infant Mental Health Services at Tulane University in New Orleans, Louisiana. As lead author of the guidance, she says this is the first policy statement focusing on nonpharmacologic interventions for emotional and behavioral problems in children and reflects a growing awareness that children can face mental health problems that impact their growth and development. The policy statement also addresses the issue of access.

“The evidence-based treatments have substantially more data supporting them than medications, but only 1 in 2 children with attention-deficit/hyperactivity disorder (ADHD) receives behavioral therapy, in part because there are insufficient numbers of therapists providing the treatment and also, perhaps, because these treatments have not been a focus of pediatric residency training and many pediatricians are not as comfortable with these treatments as with medications,” Gleason says.

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There is growing evidence that demonstrates the efficacy of family-focused therapies in improving emotional, behavioral, and relationship problems, according to the statement, but access to these therapies can be a challenge. In many areas of the country, there is limited access to pediatric mental healthcare providers and pediatricians become the primary provider. However, many pediatricians have only rudimentary training in mental health care and can be overwhelmed at the prospect of providing therapeutic interventions outside of medication.

The problem is significant, with an estimated 7% to 10% of children facing emotional or behavioral problems, according to the statement-and they have a big impact.

“Emotional, behavioral, and relationship problems, including disorders of attachment, disruptive behavior disorders, ADHD, anxiety and mood disorders, and disorders of self-regulation of sleep and feeding in children aged younger than 6 years, interfere with development across multiple domains, including social interactions, parent-child relationships, physical safety, ability to participate in child care, and school readiness. Importantly, if untreated, these problems can persist and have long-lasting effects, including measurable abnormalities in brain functioning and persistent emotional and behavioral problems. In short, early emotional, behavioral, and relationship problems in preschool-aged children interfere with their current well-being, jeopardize the foundations of emotional and behavioral health, and have the potential for long-term consequences.”

Existing policy statements have addressed universal approaches to pediatric mental health care, but this is the first to focus on clinical interventions. There has been little research on the use of mental health medications in young children, and although nonpharmacologic interventions are backed by evidence-based research, most children with behavioral or emotional problems receive no interventions at all.

The first step to increasing access to these interventions is to familiarize pediatricians with the approaches and provide them the tools to make them available to their patients.

For infants and toddlers, the policy statement recommends dyadic interventions that promote attachment security and emotional regulation. These interventions can include infant-parent psychotherapy, video feedback to promote positive parenting, and attachment biobehavioral catch-up.

“These interventions often use real-time infant-parent interactions to support positive interactions, enhance parents’ capacity to reflect on their parenting patterns, and promote sensitivity and an understanding of the infant’s needs,” the policy states.

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For preschool-aged children, the authors recommend parent management training models such as parent-child interaction therapy, the Incredible Years series, the New Forest Program, Triple P (Positive Parenting Program), and Helping the Noncompliant Child. These interventions reinforce positive behaviors and ignore low-level provocative behaviors while providing clear, consistent responses to unacceptable behaviors.

Cognitive behavioral therapy is effective in addressing posttraumatic stress disorder and anxiety disorders, according to the statement.

Gleason says the new policy statement is important first and foremost because it acknowledges the problem patients and pediatricians face in dealing with childhood mental health problems. “I think the most important message is that these disorders exist, they cause suffering, and that many children respond to these evidence-based treatments,” Gleason says. “Early intervention may have the potential for shaping a child’s developmental trajectory by reducing their suffering, allowing them to participate in typical activities, and increasing their ability to organize their feelings when they are sad, angry, or frustrated.”

For clinicians, Gleason says she hopes the statement can help them realize that they are not alone in treating these disorders, particularly pediatricians who may not be well-trained in treating mental health disorders but somehow have become the default providers for these children.

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“I want them to feel that they can seek out any additional information or training they need to feel comfortable with the disorders, but that they also have confidence in talking to parents about the disorders and the potential treatment approaches,” Gleason says. “Using the HELP (hope, empathy, loyalty, language, permission, plan) mnemonic developed by the AAP Task Force on Mental Health allows pediatricians to use evidence-based approaches to communication around mental health issues and can decrease parent stress, even if access to the evidence-based treatment seems limited locally.”

On a larger scale, Gleason says she hopes the statement will pave the way for AAP and other organizations to advocate for increased access to pediatric mental health services through adequate reimbursement, incentivized training, and research that identifies the key components of these treatments to facilitate broader dissemination. 

Recommendations laid out in the statement include advocating for more legislative and research efforts to increase access to evidence-based mental health therapies for children, as well as for adequate funding and workforce problems in meeting those needs. Third-party payers can create barriers for addressing mental health care for children, and pediatricians should work to promote accountable care organization regulations that support appropriate care. Pediatricians should also work with local government and private agencies to explore alternative paths for treatment, and work with early childhood mental health providers and school resources. Work must also be done to stress the importance of mental health care training in graduate and continuing medical education, so that pediatricians are competent to assess and treat children with mental health problems in the absence of specialized caregivers.

Until that happens, though, Gleason says pediatricians need to work closely with parents and support them.

“Parents need to know they are not alone and that their pediatrician is committed to working with them. So many parents of children with mental health concerns can feel isolated or even blamed by people around them or themselves, so knowing that their pediatrician can help them understand the problem and offer support is a major intervention, in and of itself,” Gleason says. “Even when evidence-based treatment is not immediately available, it is valuable for pediatricians to consider these children as ‘children with special health needs’ who are followed more closely than healthy children and therefore get more support.”

Gleason adds, “[It] is incredibly valuable for pediatricians to check in with parents and encourage them to take care of themselves as well as their child. Using the airplane oxygen analogy, that you need to put your own mask on first, can be a helpful approach to encourage parents to seek out the support they need to be sensitive, patient, and consistent with their child.”