Guiding principles in managing pediatric mental health issues

Sixteen years ago, 15 of my colleagues and I—with the support of the new nonprofit REACH Institute—recognized the drastic shortage of child and adolescent psychiatrists and child psychologists, 2 essential specialties for addressing pediatric mental problems. Because most children in the United States have access to a primary care clinician (PCC), we reasoned that if children’s PCCs could become “first responders” to manage the most common (and treatable) pediatric mental health problems, we could begin to address the workforce short- ages in child mental health. It was clear then— and even more so now—that most PCCs receive little training in pediatric mental health during their residency. Ironically, current news reports about the urgent lack of pediatric mental health services are only refocusing our national attention on the crisis identified by the US surgeon general more than 20 years ago.¹

While reviewing strategies to address the problems, we learned that many traditional continuing medical education (CME) courses, useful for so much physician learning, did not prepare general pediatricians in this regard.² Instead, we drew on training techniques from adult education and basic behavior change science.³ After 2 years of development, we launched a new, hands-on, sustained coaching program for PCCs to deliver mental health services in primary care practice.

During program development, we realized that fear of the unknown could interfere with PCCs’ willingness to address pediatric mental health problems. Ironically, we also recognized that PCCs do learn to diagnose and manage many other serious illnesses simultaneously managed by specialists (eg, asthma by pulmonologists, diabetes by endocrinologists, eczema by dermatologists). They learn about effective medicines to ameliorate these illnesses and about potential adverse effects (AEs). In any illness in children, PCCs—with family knowledge/consent—learn to prescribe medications (along with other interventions), even those with potentially severe/fatal AEs, recognizing that the illness is generally riskier than the treatment (eg, penicillin vs anaphylaxis, steroids vs cataracts or psychosis). Accordingly, we determined that for PCCs to become effective first responders for common pediatric mental illnesses, the skill elements mentioned must underpin the training.

However, consider the dilemma for a PCC who faces a new pediatric patient with chronic disruptive behaviors and irritability. If this PCC does not have confidence in their skills to assess and diagnose this case, how can they know whether the child has attention-deficit/hyperactivity disorder (ADHD)? Or depression? Or if family conflict and impending divorce are affecting the child? Will treating the possible ADHD make some underlying condition worse?

Thus, we decided that our new pediatric workforce training program must place a strong emphasis on assessment and diagnostic skills. Furthermore, we realized that our training must help PCCs conceptualize pediatric mental health problems within the context of what is known about the biopsychosocial influences on a child’s development, including development of mental health problems.

Based on the need for a clear logical framework for the training, we developed a set of “first principles”— guiding values and practices to pilot PCCs through the process of problem identification, diagnosis, and treatment, including deciding when, whether, and how to use a medicine, along with other appropriate interventions.

In the REACH Institute’s 16-plus years’ experience of coaching, reaching more than 5000 PCCs, these principles have been well received and very effective in providing PCCs the knowledge and skills to become powerful new agents in local mental health care systems, helping them manage common pediatric mental health problems (eg, anxiety, depressive disorders, ADHD, disruptive disorders, and their combinations).³

Because these principles and practices have broad applicability, we hope that PCC training programs generally (both graduate medical education and CME programs) will consider their application. We present details of these principles and practices in the Table. Many of the principles are already consistent with how PCCs are initially trained and approach treatment of other chronic conditions, such as asthma, diabetes, and allergies.

REACH Institute "First Principles"

These principles fall under 4 major categories: (1) developmental and contextual assessment and understanding; (2) team formation, communication, and shared decision-making; (3) do no harm—considerations for prescribing medications; and (4) evidence-based prescribing practices.

Developmental/contextual assessment

The first general category is a sine qua non prior to developing any ap- propriate mental health interventions. We find that when present- ed with an unfamiliar behavior or emotional problem, PCCs may cognitively freeze, forgetting to do what they do with other illnesses, and fail to inquire about all relevant aspects of the child’s and family’s life that might contribute to or precipitate the problem(s). They may forget to ask the questions “What are the current stressors for all? Why do you [parents and youth, if old enough] think this is happening? What has changed recently? What do we know about the child’s peers and school setting?” At this initial stage, the PCC should not worry about time: Most cases are not a true emergency (even if a parent feels it is), so the PCC must communicate patience and reassurance and schedule follow-up visits to obtain additional information from school records and past evaluations.

PCCs also may worry that they do not know the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) in all its complexities, but that level of knowledge is rarely needed. Instead, during an initial visit, it is more important to understand what is going on in the child’s and family’s life. DSM-5 diagnoses often become clearer over time and with more information.

The last point under this first general principle is to remember that “pills do not create skills,” and the sole use of medication is rarely if ever a solution. Medications are just 1 part of a meaningful, effective treatment plan.

Team formation and communication and decision-making

Involve the family and child in decision-making before recommending any treatments. Attempts to overpersuade the family to pursue a given treatment are ultimately ineffective. If the family is reluctant about a specific treatment, first figure out why, and determine what additional education and support are needed. Consider, for example, keeping a library of books on hand to show and recommend to families. Link them to other parents who have experienced similar difficulties by recommending that they join a parent advocacy organization, such as Children and Adults With Attention-Deficit/Hyperactivity Disorder⁵ or the National Alliance on Mental Illness.⁶ Participating in such groups (via either online chat groups or local chapters) will expose them to other parents who have learned the ropes of having a child similar to theirs.

Ongoing education and support will help families learn about their child’s condition and become proactive in its management. This takes time, along with the PCC’s continuing encouragement and guidance.

The training addresses several other key principles within this category, including helping PCCs prioritize when a child has multiple problems. In addition, PCCs are taught to obtain objective evidence-based assessments (eg, rating scales) to identify and track the child’s progress.

Do no harm: Considerations for prescribing medications

When prescribing psychiatric medications, PCCs are encouraged to remember that children and adolescents are different from adults on multiple fronts. They may have more, fewer, or different AEs. For example, younger children treated with a stimulant may cry easily for no apparent cause, a symptom that disappears as soon as the medication is stopped. Children have higher metabolic rates than adults and may require proportionally higher doses because of greater kidney clearance and higher liver to body mass ratios. These considerations warrant careful monitoring for possible AEs.

Given the somewhat greater uncertainties when using psychotropic medications in children, these medicines (if indicated) should be used at research-documented doses and durations within placebo-controlled randomized controlled trials. Fortunately, over the past 2 decades, multiple multisite, definitive, federally funded trials have shown the appropriate doses to achieve optimal responses for children with common behavioral and emotional disorders.^7-9 These findings are taught in all graduate and CME programs.

Another principle is the common psychopharmacologic aphorism “start low, go slow, and taper slow.” If the need to discontinue a medication arises, a second (but not exclusive) rule is to taper the medication over 2 to 3 weeks, with some exceptions. Lastly, clinicians should monitor and measure possible AEs and teach parents and youth about any AEs they should watch for.

Evidence-based prescribing practices

The final major category, use of evidence-based prescribing practices, has multiple components. First, participants are encouraged to use only medicine supported by double-blind, randomized, controlled trials for the child’s age and diagnosis. They are encouraged to minimize use of multiple medications (polypharmacy) and maximize use of single medications. For example, a second medication for a problem such as ADHD should not be added before trying the maximum level of the initial medication.

If a child is receiving more than 1 medication and a change appears essential (due to either lack of benefit or to AEs), just 1 medication at a time should be changed, with appropriate rating scales used to monitor changes in benefits or AEs.

The benefits of modifying the child’s environment, rather than the medication, must also be considered. For example, if a child with ADHD is doing poorly in school and there is clear evidence that the child and teacher are not getting along, consider whether a classroom change might be just as helpful and possibly a better strategy.

When a medication change is indicated, PCCs are taught to carefully consider timing and avoid overlap with other changes in the child’s life. For example, changing or stopping a medication right before or during a critical event may lead to uncertainty about the cause of any subsequent behavior change. Last, PCCs are encouraged to evaluate the iatrogenic effects of medicines and determine whether any given behavioral problem could be due to the child’s medicine regimen.

Conclusion

We believe that if all PCCs apply these principles and practices, over the course of their professional careers, they will be able to address as many as 75% of children with mental health problems. This dramatic expansion in our pediatric mental health workforce, due to a new cadre of trained and prepared first responders—pediatricians, family physicians, nurse practitioners, and physician assistants—could largely redress the terrible insufficiencies of our current pediatric mental health care due to lack of specialists.

More than 20 years ago, the surgeon general outlined the necessity of addressing the children’s mental health crisis via training the primary pediatric workforce in critical mental health skills.¹ Sadly, since then, between children’s rising mental health needs (including related to the COVID-19 pandemic) and the actual number of pediatric mental health specialists, the gap has only widened.¹⁰ We have attempted to follow the surgeon general’s advice by training many primary care colleagues through our 6-month coaching program.^3,4 Although we have been heartened to see so many of our pediatric colleagues transform their practices to serve children with mental health problems, if we all want to look back in another 20 years and see genuine progress, much more is needed.

For more on the REACH Institute, visit https://thereachinstitute.org/

References

1. US Department of Health and Human Services; US Department of Education; US Department of Justice. Report of the Surgeon General’s Conference on Children’s Mental Health: A National Action Agenda. US Department of Health and Human Services; 2000. Accessed March 1, 2022 https://www.ncbi.nlm.nih.gov/books/NBK44233/

2. Thomson O’Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Syst Rev. 2001;(2):CD003030. doi:10.1002/14651858.CD003030

3. Love AR, Jensen PS, Khan L, Brandt TW, Jaccard J. The basic science of behavior change and its application to pediatric providers. Child Adoles Psychiatr Clin N Am. 2017;26(4):851-874. doi:10.1016/j.chc.2017.06.011

4. Training. The REACH Institute. Accessed February 3, 2022. https://www.thereachinstitute.org/training/#online-training

5. Children and Adults With Attention-Deficit/Hyperactivity Disorder. Accessed February 3, 2022. https://chadd.org

6. National Alliance on Mental Illness. Accessed February 3, 2022. https://nami.org/Home

7. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavior therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008:359(26):2753-2766. doi:10.1056/NEJMoa0804633

8. March J, Silva S, Petrycki S, et al. Treatment for Adolescents With Depression Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA. 2004;292(7):807-820. doi:10.1001/jama.292.7.807

9. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal treatment study of children with ADHD. Arch Gen Psychiatry. 1999;56(12):1073-1086. doi:10.1001/archpsyc.56.12.1073

10. Workforce issues. American Academy of Child & Adolescent Psychiatry. Updated April 2019. Accessed February 3, 2022. https://www.aacap.org/aacap/Resources_for_Primary_Care/Workforce_Issues.aspx