There are roughly 15% of the nation’s children who suffer from a developmental-behavioral condition or about 1 in 6 children. Unfortunately, many of those children often do not get the help they need.
Children with developmental and behavioral challenges can easily be missed, especially when the behaviors are more subtle or impacts on function are not evident daily, such as with a child who has anxiety or a learning disability. However, when children show signs of aggression, defiance, truancy or have co-existing medical conditions like seizures or developmental delays, it may create tension and stress in the child’s interactions with peers or family. Sometimes, it is only when behaviors are severe or affect others that medical attention is sought.
Unlike other medical conditions such as a strep throat or pneumonia which can be diagnosed with a medical test, behavioral conditions are tricky because there is not a specific medical test that can or should be used.
In our nation, we are facing a crisis of epidemic proportions. It cannot be denied that the number of children who are experiencing anxiety and depression are increasing. There is not one single factor accounting for the increase, but rather a host of issues that have created a “perfect storm.” Many of these relate to the type of world we live in today and include exposures to trauma and violence, less face-to-face interactions and social supports, exposures to graphic images online, changes in family structures and more. Even so, there is an even bigger problem with the national shortage of qualified child providers trained to identify and manage these types of conditions. Further compounding the problem are factors like stigma, insurance coverage and access to the number of providers who take Medicaid that also limits the number of children and teenagers receiving timely treatment.
So, whose responsibility is it to identify and manage these conditions?
It is the front line providers (general pediatricians, family physicians, advance nurse practitioners and physician assistants) who encounter children and teenagers with behavioral and mental health challenges, sometimes on a daily basis. But almost two-thirds of those front line providers don’t necessarily feel equipped to handle those challenges. Why? Lack of training is one reason, especially as the complexity and severity of those conditions have increased. Another reason is lack of time. Primary care practices are high volume by nature. Even though reports show that the average time has actually increased, visits are usually under 20 minutes. Twenty minutes is just not enough time to unpack behavioral concerns.
On the other hand, families often encounter long waitlists to sub-specialists, such as developmental-behavioral pediatricians, neurodevelopmental pediatricians, psychologists and child psychiatrists. There just aren’t enough of them to meet the need. The shortage is even more pronounced in rural areas that commonly have even less resources. Unfortunately, this workforce is aging and the number of new providers going into these subspecialties is just not keeping up with the demand. Thus, the “pipeline” of younger providers completing specialty training to care for these children is at a trickle and that’s a problem.
The problem may end up hurting everyone.
Families might be referred to see a specialist and end up waiting months. They often have no supports for what to do in the interim. Primary care providers are caught in the middle. Many feel as if they have no choice but to begin taking care of these conditions even if they might not feel comfortable. Frontline providers may end up making several referrals to multiple providers at once, hoping whoever has the shortest waiting list can see the family as soon as possible. This is problematic because sometimes families may not always understand which doctor appointments are a priority. They may decide to not show if the child is “doing better” because inevitably these behaviors may wax and wane. Or families may end up seeing multiple specialists for the same issue and end up feeling frustrated or overwhelmed.
What can be done?
Increasing visibility of these issues is key. There are efforts to increase behavioral health knowledge and skills for those already in practice with the creation of mini fellowships or certificate programs. Changes to curriculum during residency programs to ensure exposure before going out into practice is already happening. The use of telemedicine and improving reimbursement rates are additional strategies to boost access, quality and affordability of care. Since the workforce is limited, optimizing generalist-specialist collaboration through child psychiatry access programs and integrated behavioral health in primary care settings. It likely may also take supporting programs delivered in non-traditional settings, such as the schools. We can take a more preventive approach through evidence-based home visiting programs and supporting the use of group care focusing on strengthening parenting efforts as ways to prevent or “slow down” rates of emerging mental health issues.
On top of all this, a record number of physicians are battling burnout, experience depression or committing suicide. Supporting the workforce should be among the top priorities for hospital systems and administrators. When the providers themselves are burned out, it can lead to an increase in medical errors, decreased patient satisfaction and providers feeling disenchanted, disconnected and contemplating leaving medicine altogether. Caring for children with difficult and challenging life circumstances has been tied to burnout and compassion fatigue, which in the end helps no one.
Please don’t forget those of us who work tirelessly and advocate for child health
It will obviously take a concerted tremendous push to redesign our behavioral health care system and re-evaluate the effects of these systems-level policies and changes. Social capital investments in our children should remain at the forefront and is always a smart investment. However, we cannot neglect those in the trenches who care tirelessly for these children. We must acknowledge our developmental behavioral pediatric workforce and pay attention to their viability. It is the only way to ensure high quality care for families most in need within a system that still needs a lot of work.