The role of the pediatrician in school-based mental health services

James Wallace, MD

Navigating school-based mental health services can be difficult for a child with mental health issues, their family, and at times, for the pediatrician.

James Wallace, MD, associate professor, Department of Psychiatry and Pediatrics, University of Rochester Medical Center, Child and Adolescent Psychiatry Faculty Trainer, The REACH Institute, explained how to traverse the crossover landscape between the pediatrician and school, in this Q+A interview with Contemporary Pediatrics.

Contemporary Pediatrics:

What is the pediatrician’s role when it comes school-based mental health services?

James Wallace, MD:

The single most important thing pediatricians can do is to consider the school as a natural and important ally and partner for managing pediatric behavioral health issues. Collaboration can help us make more accurate diagnoses, develop more effective multimodal treatment plans, and monitor progress in many areas. Without collaboration and communication, there are always missing pieces.

Contemporary Pediatrics:

How can schools and pediatricians work better together, or what are the missing links?

Wallace:

Medicine and education have different ways to think about children and teens. Each uses different language, follows different laws and regulations, and uses different strategies to intervene. Therefore, collaboration requires that both parties work hard to understand each other.

Simple routine communication procedures like sending the pediatrician a copy of every Individualized Education Plan (IEP) and 504 Accommodation Plan can help. Pediatric offices could develop a liaison for schools, [such as] clerical, medical assistant, nurse, and schools could develop a liaison for medical offices, [such as] clerical, teacher on special assignment, school nurse, counselor, or administrator.

To follow confidentiality laws (HIPPA, FERPA), having convenient releases of information (ROI) and making routine communication an expectation are huge steps in the right direction.¹

Contemporary Pediatrics:

When is a good time to refer a patient to a mental health professional, perhaps going from a school therapist or counselor to something more?

Wallace:

When children and teens need evidence-based care that the school cannot provide, referring to community resources for that care is critical. Both schools and PCPs should keep a list of providers in the community with whom they have had good experiences and share that resource list.

Many states have Child Psychiatric Access Programs² where primary care providers can call to get a list of appropriate referrals. But it is not an either/or. Students often continue with their school-based counseling as they enter community-based services. Collaboration between these 2 providers using the same language and skill-building can boost the impact of interventions and help generalize changes to more settings.

Contemporary Pediatrics:

What are schools and pediatricians lacking when it comes to providing resources to children with mental health concerns?

Wallace:

A school and pediatrician team can effectively assess and manage many, perhaps most, mental health concerns in children and teens, especially if the pediatric provider had intensive training in the assessment and management of mental health problems like the Patient-centered Mental Health in Pediatric Primary Care (PPP4) course offered through the REACH Institute.³

Primary care providers can also learn time-limited evidence-based Cognitive Behavior Therapy, Parent Training and Trauma interventions that they can provide themselves for milder cases or for when access to community therapy resources is delayed or unavailable.

Children with complex symptoms and impairment often need services and expertise beyond this core team. They often need a more specialized clinical therapist in the community. Some need consultation and treatment with a child and adolescent psychiatrist or psychiatric nurse practitioner.

Others need care management, in-home services, crisis services and acute care services beyond the resources of schools and primary care providers. These services are in addition to the school-pediatrician team, not instead of.

As the complexity and impairment expands, the “village” of collaborating providers needed to support the family and child should grow to meet the need. Call Access Programs can be a great resource for primary care providers to learn how to use the complex and often unique network of available local services.²

Contemporary Pediatrics:

Who are the students who are most vulnerable to mental health issues?

Wallace:

Children and teens who have suffered significant trauma are a very vulnerable group who are often in need of mental health service. Behavioral health problems have genetic and environmental components (nature and nurture), so they tend to run in families, especially when the whole family is struggling.

Those who have experienced adverse childhood events (ACES) are at risk, as are children who have been bullied, who are engaged in substance use, or who are in the LBGQT+ community. Non-English speakers, recent immigrants, people of color and other minority groups are at risk due to chronic stressors. They also face complex barriers to adequate health and mental health services, so they suffer doubly with greater needs and worse access.

Contemporary Pediatrics:

What signs should pediatricians and teachers/counselors look for in these patient populations?

Wallace:

Abrupt changes in mood, behavior, academic performance and/or relationships are worrisome signs. School refusal, self-injury or suicidal comments or behaviors, verbal or physical threats or aggression are red flags.

Subtle changes can signal a possible behavioral health problem early when the problems and impairment are milder and more amenable to change. School personnel and primary care providers have the advantage of knowing their students/patients over time so they can tell when a child’s behavior changes. Familiar faces make it easier for students/patients and their families to disclose their concerns and seek help.

In medical settings, the United States Preventative Services Task Force (USPSTF) recommends universal screening for high frequency mental health problems like anxiety, depression, and suicidality—available on the ProjectTeachNY.org website—because some patients and families don’t disclose their concerns unless asked.^1,4

Some school districts have screening protocols for the same reason. We must all be on the lookout for significant changes in mood, anxiety, aggression, relationships, and academic performance so we can help these students/patients and all children and teens get the help they need.

References:

1. Families thrive with good mental health. Project Teach. Accessed February 9, 2024. https://projectteachny.org/

2. Integrating physical and behavioral health care for every child. National Network of Child Psychiatry Access Programs. Accessed February 9, 2024. https://www.nncpap.org/

3. REACH mental health training. The REACH Institute. Accessed February 28, 2024. https://thereachinstitute.org/training/#patient-centered-mental-health-in-pediatric-primary-care-ppp

4. Mental health conditions and substance abuse. US Preventive Services Task Force. Accessed February 9, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/topic_search_results?category%5B%5D=20&searchterm=