Why Integrated Behavioral Health Care for Children and Adolescents Matters

Published in Brain Wise - Brainwise Spring/Summer 2022

By the time Nadia Zaim joined the faculty at Johns Hopkins Medicine in 2020 as a child and adolescent psychiatrist, she’d cared for hundreds of children grappling with mental illness — intensified by the COVID-19 pandemic. These illnesses include anxiety, depression, and attention deficit/hyperactivity disorder (ADHD) among others. Board-certified in general pediatrics, adult psychiatry and child and adolescent psychiatry, Zaim supports children, adolescents, and young adults who are navigating the relationships and stressors of growing up while living with mental illness.

Demand for these services has never been higher, she says. In early December of 2021, the U.S. surgeon general issued an advisory: “Youth Mental Health Crisis Further Exposed by the COVID-19 Pandemic,” noting the “unprecedented impacts on American youth and their families.” Well before the pandemic emerged, the surgeon general reported that mental health challenges were the leading cause of disability and poor life outcomes in young people — with up to one in five children ages 3 to 17 in the U.S. having a mental, emotional, developmental or behavioral disorder, and suicide ranking as the second leading cause of death for children ages 10-14.

That said, Zaim remains hopeful that “integrated” behavioral health care — a model of mental health care delivery centered in the primary care pediatrician’s office — can make a significant and potentially lifesaving difference. An integrated mental health care model is one of the best ways to reach children in need of mental health care, she says: “A robust program can provide proactive support, support pediatricians seeing patients with mental health needs, increase access for patients who may otherwise not be able to attend mental health appointments, and can meet patients in a health care setting where they feel most comfortable.” 

Zaim’s clinical work has focused both in primary care and acute care settings. Every day, she sees children who present to the pediatric emergency department in mental health crises, who are admitted to pediatric floors with comorbid mental illness, and she has been working with a team of core clinicians in general pediatrics, internal medicine/pediatrics, and child psychiatry on developing a pilot program in integrated care. These include Monica Mix, Edith Dietz and Rheanna Platt. Given Zaim’s experience in these settings, she worries about limited resources and the national shortage of child psychiatrists. 

In a recent conversation, Zaim described how she’s working to improve the odds for vulnerable young patients. 

How has the pandemic affected your clinical work? 

The pandemic allowed us to think outside of the box, as we were developing our first iteration of the integrated care program. We were able to get around barriers, such as billing regulations and lack of physical space in clinics, by providing telemedicine appointments for patients in need of an outpatient psychiatry consultation. We were also able to see patients without requiring them to drive to a clinic, which we hope has helped to increase access to care for those without easy transportation. With regard to my consults and emergency department coverage, the pandemic led to a substantial increase in the number of young patients who have come into the hospital in psychiatric crisis after a suicide attempt or with significant mental illness. We've seen patients who are sicker and who had to wait longer to access resources. This has continued to reaffirm the importance of an institutional investment in integrated care as a way to increase access for patients earlier in the course of mental illness. With this approach, we can practice preventive medicine — in hopes of minimizing the number of patients whose illness worsens because they cannot access care.
Without using names, can you provide examples of pediatric patients with psychiatric issues who have benefitted from these services? 

Through our integrated care program, we've been able to see patients starting at age 5 up to young adults. The most rewarding thing about caring for patients in this setting is that the spectrum of illness is much broader than that of patients who come into the Pediatric Emergency Department in crisis. So we often see patients with more mild illness who respond relatively quickly to our interventions. We've seen adolescents with anxiety do really well after starting medications, and other patients who have struggled with aggression in the setting of developmental and intellectual disability benefit from medications. Because we are seeing patients on the mild end of the illness spectrum, we also see many patients for whom we recommend therapy without the need for medications and who do well, once they are in regular therapy.
To what extent do you involve parents and siblings in the treatment? 

We always involve parents or guardians in treatments, as they are our allies and work to help make sure our patients are getting the care they need. We don't often involve siblings, unless a patient is specifically in family therapy. 
Which specialties are most likely to provide psychiatric services for pediatric/adolescent patients?  

We're fortunate to have two strong psychology teams at our children’s center who see patients who are admitted, as well as those embedded in many clinics. These clinicians consult on patients in urology, cardiology, hematology/oncology, endocrinology, gastrointestinal (GI) and many other specialty clinics. The psychology teams also help to provide care for patients with pain, traumatic brain injury, feeding disorders and functional neurologic disorders. Psychiatry is not yet embedded in all of these subspecialty clinics, but we do see patients in the integrated care setting in primary care. We still need to boost psychology and social work services in primary care clinics and expand our bandwidth to provide psychiatry in subspecialty clinics, as well.
What are you most proud of? 

The thing that I'm both proud of but need to continue working on is fighting stigma against mental illness that is so prevalent not only in society but also in healthcare settings. I’ve made it my mission to teach as many pediatricians about mental health as possible, with a goal of helping our colleagues on the front lines both understand and feel comfortable treating mental illness. The more physicians who feel comfortable assessing and treating mental illness, the more we can come together to fight the stigma of mental health in our society.

How do you envision the future of integrated mental health care for children? Are you hopeful? If so, why? 

I am not sure that we are ever going to have enough child psychiatrists to satisfy the need, so I strongly believe that the future of child psychiatry requires educating pediatricians, as well as investing in integrated and collaborative care programs. Doing so will help us expand access to care both by supporting pediatricians in the primary care setting to manage mental illness, as well as having a first-line access to care with psychology, social work and psychiatry in primary care clinics. My hope is that with further program building, we can work towards early intervention and prevention of illness progression, as well as treating mild — and sometimes moderate — illness in primary care. This approach will allow for shorter wait times for those patients who end up needing access to psychiatry specialty care. Programs like these have been successful in many other institutions, and there’s a growing understanding of the need, given the recent national emergency in mental health. I'm hopeful that with the groundswell of interest and need from pediatricians and med/peds physicians, as well as from our psychology, social work and psychiatry teams, we can work together to expand integrated care programming and increase access to mental health services.

Learn more about child and adolescent mental health resources at Johns Hopkins. 

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