Child Psychiatry Consult

“Allie” is a 16-year-old African American female, presenting to her primary care provider for a routine well-child visit. She gets straight As in school, has a boyfriend, and works as a lifeguard. She is always on her phone using Snapchat, TikTok, and Instagram. Over the past year, it’s been taking her longer to turn off the phone and electronics at night. She needs to close the apps one by one and check the power sources a number of times. In the past few months, this ritual has become longer, includes more checks, and is interfering with sleep. She reports knowing this is abnormal and thinking she is “just kind of crazy” but she cannot stop. Her parents reassure her each evening. They now help her doublecheck that her devices are plugged in at least twice.

Unlike its depiction in the movies, many symptoms of obsessive-compulsive disorder (OCD) happen internally. Often patients are aware that these are “not normal” and cover up their experiences. It can be hard for treaters to learn about these challenges. Children spend years suffering from OCD and even regularly attend nonspecific therapy without being diagnosed. However, targeted treatment dramatically improves the life trajectory of those with OCD.

Dr. Spottswood

OCD impacts 2.3% of the population in their lifetime but more than 28% of people report symptoms consistent with OCD traits.¹ OCD symptoms have increased since the pandemic² so it is showing up in primary care more frequently. Younger patients meet criteria when their symptoms on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) are sufficiently present, and impact the ability to function. The youngest patients with OCD are more likely to be male¹ and children are most likely to be identified between ages 8-12 and during the later teenage years,³ although symptoms can occur at any time in life.

Usually, symptom onset happens gradually and then waxes and wanes. Often OCD has been present over months to years but not identified until they reach a functional tipping point. Alternatively, symptoms caused by PANDAS/PANS occur out of the blue and should be treated according to infectious disease/autoimmune workup protocols. Other differential diagnosis for OCD include other anxiety disorders, mood disorders, eating disorders, psychotic disorders, and other compulsive behaviors. OCD, tics, and ADHD are a combination seen more frequently in younger patients.⁴ Comorbidities frequently occur, including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders.¹ PTSD frequently presents with comorbid OCD symptoms.¹ Finding the underlying cause is key to effective treatment.
 

How do I identify OCD in primary care?

Administer the CY-BOCS if these symptoms cause inability to function. The cut off for moderate symptoms is a score of 16 or above. Like all mental health screening, clinical judgment should be used to interpret the score. Many therapists do not screen for OCD.

How do I treat OCD in primary care?

Exposure Therapy with Response Prevention (ERP) is the gold-standard therapy and medication management is most effective when paired with ERP. ERP helps patients list their obsessions and compulsions in order of how much anxiety they cause, then work on gradual exposure starting with those that cause the least amount of anxiety. Picking up on any sneaky internal or external “responses” is important. An example response could include externally checking the rearview mirror to make sure the patient didn’t run over a puppy after they hit a pothole, or internally reassuring themselves. This “response prevention” can be the trickiest part of the therapy and is key to efficacy.

How to access ERP?

The International OCD Foundation offers a list of therapists trained in ERP, and most states’ psychiatry access lines can help primary care providers find available targeted resources. Despite these resources, it can be frustrating to help a family try find any available therapist who takes insurance, let alone a specialist. A recent JAMA article review found that IInternet-based treatment with both therapist- and non-therapist–guided interventions resulted in symptom improvements.² Interventions that include parents are most helpful for children.

Other therapy options include:

• MGH/McLean/ (iocd.org) hosts an online, low cost ($65 per family) OCD camp for those age 6-17 and caregivers found here.
• Many workbooks are available, Standing Up to OCD Workbook for Kids by Tyson Reuter, PhD, is one good option.
• A book for parents about how not to accidentally reinforce anxiety is Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle by Lynn Lyons and Reid Wilson.
• Sometimes a therapist without expertise can work with families using workbooks and other supports to help with ERP.

Medication options

Medications alone do not cure OCD, but can help patients better participate in ERP therapy. When the most likely cause of OCD symptoms is OCD (ruling out family history of bipolar or other psychiatric illness), using SSRIs to treat symptoms is the gold standard for medications. There is FDA approval for sertraline (≥ age 6) and fluoxetine (≥ age 7) as first-line options. If tolerated, up-titrate to efficacy. Clomipramine and fluvoxamine also have FDA approval but have more side effects so are not first line. Citalopram has randomized clinical trial support.⁵

Allie’s primary care provider administered and scored the CY-BOCS, started her on an SSRI, and up-titrated to efficacy over 4 months. The family signed up for an online OCD camp and learned more about OCD at iocdf.org. They talked with her therapist and worked through an OCD workbook together as no specialist was available. Her parents decreased their reassurances. Because of her primary care provider’s intervention, Allie got the care she required and was better prepared to face future exacerbations.
 

Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont. She is the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.

References

1. Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Jan;15(1):53-63. doi: 10.1038/mp.2008.94.

2. Lattie EG, Stamatis CA. Focusing on accessibility of evidence-based treatments for obsessive-compulsive disorder. JAMA Netw Open. 2022;5(3):e221978. doi: 10.1001/jamanetworkopen.2022.1978.

3. International OCD Foundation pediatric OCD for professionals. https://kids.iocdf.org/professionals/md/pediatric-ocd/. Accessed December 27, 2023.

4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2013. https://doi.org/10.1176/appi.books.9780890425596. Accessed December 27, 2023.5. Hilt RJ, Nussbaum AM. DSM-5 pocket guide to child and adolescent mental health. Arlington, Virginia: American Psychiatric Association Publishing, 2015.

“Allie” is a 16-year-old African American female, presenting to her primary care provider for a routine well-child visit. She gets straight As in school, has a boyfriend, and works as a lifeguard. She is always on her phone using Snapchat, TikTok, and Instagram. Over the past year, it’s been taking her longer to turn off the phone and electronics at night. She needs to close the apps one by one and check the power sources a number of times. In the past few months, this ritual has become longer, includes more checks, and is interfering with sleep. She reports knowing this is abnormal and thinking she is “just kind of crazy” but she cannot stop. Her parents reassure her each evening. They now help her doublecheck that her devices are plugged in at least twice.

Unlike its depiction in the movies, many symptoms of obsessive-compulsive disorder (OCD) happen internally. Often patients are aware that these are “not normal” and cover up their experiences. It can be hard for treaters to learn about these challenges. Children spend years suffering from OCD and even regularly attend nonspecific therapy without being diagnosed. However, targeted treatment dramatically improves the life trajectory of those with OCD.

Dr. Spottswood

OCD impacts 2.3% of the population in their lifetime but more than 28% of people report symptoms consistent with OCD traits.¹ OCD symptoms have increased since the pandemic² so it is showing up in primary care more frequently. Younger patients meet criteria when their symptoms on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) are sufficiently present, and impact the ability to function. The youngest patients with OCD are more likely to be male¹ and children are most likely to be identified between ages 8-12 and during the later teenage years,³ although symptoms can occur at any time in life.

Usually, symptom onset happens gradually and then waxes and wanes. Often OCD has been present over months to years but not identified until they reach a functional tipping point. Alternatively, symptoms caused by PANDAS/PANS occur out of the blue and should be treated according to infectious disease/autoimmune workup protocols. Other differential diagnosis for OCD include other anxiety disorders, mood disorders, eating disorders, psychotic disorders, and other compulsive behaviors. OCD, tics, and ADHD are a combination seen more frequently in younger patients.⁴ Comorbidities frequently occur, including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders.¹ PTSD frequently presents with comorbid OCD symptoms.¹ Finding the underlying cause is key to effective treatment.
 

How do I identify OCD in primary care?

Administer the CY-BOCS if these symptoms cause inability to function. The cut off for moderate symptoms is a score of 16 or above. Like all mental health screening, clinical judgment should be used to interpret the score. Many therapists do not screen for OCD.

How do I treat OCD in primary care?

Exposure Therapy with Response Prevention (ERP) is the gold-standard therapy and medication management is most effective when paired with ERP. ERP helps patients list their obsessions and compulsions in order of how much anxiety they cause, then work on gradual exposure starting with those that cause the least amount of anxiety. Picking up on any sneaky internal or external “responses” is important. An example response could include externally checking the rearview mirror to make sure the patient didn’t run over a puppy after they hit a pothole, or internally reassuring themselves. This “response prevention” can be the trickiest part of the therapy and is key to efficacy.

How to access ERP?

The International OCD Foundation offers a list of therapists trained in ERP, and most states’ psychiatry access lines can help primary care providers find available targeted resources. Despite these resources, it can be frustrating to help a family try find any available therapist who takes insurance, let alone a specialist. A recent JAMA article review found that IInternet-based treatment with both therapist- and non-therapist–guided interventions resulted in symptom improvements.² Interventions that include parents are most helpful for children.

Other therapy options include:

• MGH/McLean/ (iocd.org) hosts an online, low cost ($65 per family) OCD camp for those age 6-17 and caregivers found here.
• Many workbooks are available, Standing Up to OCD Workbook for Kids by Tyson Reuter, PhD, is one good option.
• A book for parents about how not to accidentally reinforce anxiety is Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle by Lynn Lyons and Reid Wilson.
• Sometimes a therapist without expertise can work with families using workbooks and other supports to help with ERP.

Medication options

Medications alone do not cure OCD, but can help patients better participate in ERP therapy. When the most likely cause of OCD symptoms is OCD (ruling out family history of bipolar or other psychiatric illness), using SSRIs to treat symptoms is the gold standard for medications. There is FDA approval for sertraline (≥ age 6) and fluoxetine (≥ age 7) as first-line options. If tolerated, up-titrate to efficacy. Clomipramine and fluvoxamine also have FDA approval but have more side effects so are not first line. Citalopram has randomized clinical trial support.⁵

Allie’s primary care provider administered and scored the CY-BOCS, started her on an SSRI, and up-titrated to efficacy over 4 months. The family signed up for an online OCD camp and learned more about OCD at iocdf.org. They talked with her therapist and worked through an OCD workbook together as no specialist was available. Her parents decreased their reassurances. Because of her primary care provider’s intervention, Allie got the care she required and was better prepared to face future exacerbations.
 

Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont. She is the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.

References

1. Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Jan;15(1):53-63. doi: 10.1038/mp.2008.94.

2. Lattie EG, Stamatis CA. Focusing on accessibility of evidence-based treatments for obsessive-compulsive disorder. JAMA Netw Open. 2022;5(3):e221978. doi: 10.1001/jamanetworkopen.2022.1978.

3. International OCD Foundation pediatric OCD for professionals. https://kids.iocdf.org/professionals/md/pediatric-ocd/. Accessed December 27, 2023.

4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2013. https://doi.org/10.1176/appi.books.9780890425596. Accessed December 27, 2023.5. Hilt RJ, Nussbaum AM. DSM-5 pocket guide to child and adolescent mental health. Arlington, Virginia: American Psychiatric Association Publishing, 2015.

“Allie” is a 16-year-old African American female, presenting to her primary care provider for a routine well-child visit. She gets straight As in school, has a boyfriend, and works as a lifeguard. She is always on her phone using Snapchat, TikTok, and Instagram. Over the past year, it’s been taking her longer to turn off the phone and electronics at night. She needs to close the apps one by one and check the power sources a number of times. In the past few months, this ritual has become longer, includes more checks, and is interfering with sleep. She reports knowing this is abnormal and thinking she is “just kind of crazy” but she cannot stop. Her parents reassure her each evening. They now help her doublecheck that her devices are plugged in at least twice.

Unlike its depiction in the movies, many symptoms of obsessive-compulsive disorder (OCD) happen internally. Often patients are aware that these are “not normal” and cover up their experiences. It can be hard for treaters to learn about these challenges. Children spend years suffering from OCD and even regularly attend nonspecific therapy without being diagnosed. However, targeted treatment dramatically improves the life trajectory of those with OCD.

Dr. Spottswood

OCD impacts 2.3% of the population in their lifetime but more than 28% of people report symptoms consistent with OCD traits.¹ OCD symptoms have increased since the pandemic² so it is showing up in primary care more frequently. Younger patients meet criteria when their symptoms on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) are sufficiently present, and impact the ability to function. The youngest patients with OCD are more likely to be male¹ and children are most likely to be identified between ages 8-12 and during the later teenage years,³ although symptoms can occur at any time in life.

Usually, symptom onset happens gradually and then waxes and wanes. Often OCD has been present over months to years but not identified until they reach a functional tipping point. Alternatively, symptoms caused by PANDAS/PANS occur out of the blue and should be treated according to infectious disease/autoimmune workup protocols. Other differential diagnosis for OCD include other anxiety disorders, mood disorders, eating disorders, psychotic disorders, and other compulsive behaviors. OCD, tics, and ADHD are a combination seen more frequently in younger patients.⁴ Comorbidities frequently occur, including anxiety disorders, mood disorders, impulse control disorders, and substance use disorders.¹ PTSD frequently presents with comorbid OCD symptoms.¹ Finding the underlying cause is key to effective treatment.
 

How do I identify OCD in primary care?

Administer the CY-BOCS if these symptoms cause inability to function. The cut off for moderate symptoms is a score of 16 or above. Like all mental health screening, clinical judgment should be used to interpret the score. Many therapists do not screen for OCD.

How do I treat OCD in primary care?

Exposure Therapy with Response Prevention (ERP) is the gold-standard therapy and medication management is most effective when paired with ERP. ERP helps patients list their obsessions and compulsions in order of how much anxiety they cause, then work on gradual exposure starting with those that cause the least amount of anxiety. Picking up on any sneaky internal or external “responses” is important. An example response could include externally checking the rearview mirror to make sure the patient didn’t run over a puppy after they hit a pothole, or internally reassuring themselves. This “response prevention” can be the trickiest part of the therapy and is key to efficacy.

How to access ERP?

The International OCD Foundation offers a list of therapists trained in ERP, and most states’ psychiatry access lines can help primary care providers find available targeted resources. Despite these resources, it can be frustrating to help a family try find any available therapist who takes insurance, let alone a specialist. A recent JAMA article review found that IInternet-based treatment with both therapist- and non-therapist–guided interventions resulted in symptom improvements.² Interventions that include parents are most helpful for children.

Other therapy options include:

• MGH/McLean/ (iocd.org) hosts an online, low cost ($65 per family) OCD camp for those age 6-17 and caregivers found here.
• Many workbooks are available, Standing Up to OCD Workbook for Kids by Tyson Reuter, PhD, is one good option.
• A book for parents about how not to accidentally reinforce anxiety is Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle by Lynn Lyons and Reid Wilson.
• Sometimes a therapist without expertise can work with families using workbooks and other supports to help with ERP.

Medication options

Medications alone do not cure OCD, but can help patients better participate in ERP therapy. When the most likely cause of OCD symptoms is OCD (ruling out family history of bipolar or other psychiatric illness), using SSRIs to treat symptoms is the gold standard for medications. There is FDA approval for sertraline (≥ age 6) and fluoxetine (≥ age 7) as first-line options. If tolerated, up-titrate to efficacy. Clomipramine and fluvoxamine also have FDA approval but have more side effects so are not first line. Citalopram has randomized clinical trial support.⁵

Allie’s primary care provider administered and scored the CY-BOCS, started her on an SSRI, and up-titrated to efficacy over 4 months. The family signed up for an online OCD camp and learned more about OCD at iocdf.org. They talked with her therapist and worked through an OCD workbook together as no specialist was available. Her parents decreased their reassurances. Because of her primary care provider’s intervention, Allie got the care she required and was better prepared to face future exacerbations.
 

Dr. Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vermont. She is the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont.

References

1. Ruscio AM et al. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010 Jan;15(1):53-63. doi: 10.1038/mp.2008.94.

2. Lattie EG, Stamatis CA. Focusing on accessibility of evidence-based treatments for obsessive-compulsive disorder. JAMA Netw Open. 2022;5(3):e221978. doi: 10.1001/jamanetworkopen.2022.1978.

3. International OCD Foundation pediatric OCD for professionals. https://kids.iocdf.org/professionals/md/pediatric-ocd/. Accessed December 27, 2023.

4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). 2013. https://doi.org/10.1176/appi.books.9780890425596. Accessed December 27, 2023.5. Hilt RJ, Nussbaum AM. DSM-5 pocket guide to child and adolescent mental health. Arlington, Virginia: American Psychiatric Association Publishing, 2015.

Pediatricians commonly are asked to see infants presenting with symptoms of colic. The frequent and intense crying associated with colic is understandably quite distressing to parents, who often worry about a serious underlying medical cause. There also is the stress of trying to soothe an irritable infant who often does not seem to respond to the typical interventions.

Conventional wisdom about colic has been that the behaviors are the result of some gastrointestinal problem that, while not perfectly understood, tends to be mercifully self-limited and not predictive of future medical or mental health problems. This perspective then leads to pediatricians typically offering mainly sympathy and reassurance at these visits.

A new study,¹ however, challenges some of this traditional thinking. The data come from a remarkable longitudinal study called the Generation R Study (R being Rotterdam in the Netherlands) that has prospectively studied a group of nearly 5,000 children from before birth into adolescence. Colic symptoms were briefly assessed when infants were about 3 months old and emotional-behavioral problems have been prospectively measured at multiple time points subsequently using well-validated rating scales.

Dr. Rettew

The main finding of the study was excessive crying in infancy actually was significantly associated with higher levels of emotional-behavioral problems later in childhood and, to a lesser extent, in adolescence. This held for both internalizing problems (like anxiety and depressive symptoms) and externalizing problems (like defiance and aggressive behavior). At age 10, participants also underwent an MRI scan and those who were excessive criers as infants were found to have a smaller amygdala, a region known for being important in regulating emotions.

The authors concluded that colicky behavior in infancy may reflect some underlying temperamental vulnerabilities and may have more predictive value than previously thought. The connection between excessive crying and a measurable brain region difference later in life is also interesting, although these kinds of brain imaging findings have been notoriously difficult to interpret clinically.

Overall, this is a solid study that deserves to be considered. Colic may reflect a bit more than most of us have been taught and shouldn’t necessarily be “shrugged off,” as the authors state in their discussion.

At the same time, however, it is important not to overinterpret the findings. The magnitude of the effects were on the small side (about 0.2 of a standard deviation) and most children with excessive crying in early infancy did not manifest high levels of mental health problems later in life. The mothers of high crying infants also had slightly higher levels of mental health problems themselves so there could be other mechanisms at work here, such as genetic differences between the two groups.

So how could a pediatrician best use this new information without taking things too far? Regardless of the question of whether the excessive crying infancy is a true risk factor for later behavior problems (in the causal sense) or whether it represents more of a marker for something else, its presence so early in life offers an opportunity. Primary care clinicians would still likely want to provide the reassurance that has typically been given in these visits but perhaps with the caveat that some of these kids go on to struggle a bit more with mental health and that they might benefit from some additional support. We are not talking about prophylactic medications here, but something like additional parenting skills. Especially if you, as the pediatrician, suspect that the parents might benefit from expanding their parenting toolkit already, here is a nice opportunity to invite them to learn some new approaches and skills — framed in a way that focuses on the temperament of the child rather than any “deficits” you perceive in the parents. Some parents may be more receptive and less defensive to the idea of participating in parent training under the framework that they are doing this because they have a temperamentally more challenging child (rather than feeling that they are deficient in basic parenting skills).

It’s always a good idea to know about what resources are available in the community when it comes to teaching parenting skills. In addition to scientifically supported books and podcasts, there has been a steady increase in reliable websites, apps, and other digital platforms related to parenting, as well as standard in-person groups and classes. This could also be a great use of an integrated behavioral health professional for practices fortunate enough to have one.

In summary, there is some new evidence that colic can represent a little more than “just gas,” and while we shouldn’t take this one study to the extreme, there may be some good opportunities here to discuss and support good parenting practices in general.

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

Reference

1. Sammallahti S et al. Excessive crying, behavior problems, and amygdala volume: A study from infancy to adolescence. J Am Acad Child Adolesc Psychiatry. 2023 Jun;62(6):675-83. doi: 10.1016/j.jaac.2023.01.014.

Pediatricians commonly are asked to see infants presenting with symptoms of colic. The frequent and intense crying associated with colic is understandably quite distressing to parents, who often worry about a serious underlying medical cause. There also is the stress of trying to soothe an irritable infant who often does not seem to respond to the typical interventions.

Conventional wisdom about colic has been that the behaviors are the result of some gastrointestinal problem that, while not perfectly understood, tends to be mercifully self-limited and not predictive of future medical or mental health problems. This perspective then leads to pediatricians typically offering mainly sympathy and reassurance at these visits.

A new study,¹ however, challenges some of this traditional thinking. The data come from a remarkable longitudinal study called the Generation R Study (R being Rotterdam in the Netherlands) that has prospectively studied a group of nearly 5,000 children from before birth into adolescence. Colic symptoms were briefly assessed when infants were about 3 months old and emotional-behavioral problems have been prospectively measured at multiple time points subsequently using well-validated rating scales.

Dr. Rettew

The main finding of the study was excessive crying in infancy actually was significantly associated with higher levels of emotional-behavioral problems later in childhood and, to a lesser extent, in adolescence. This held for both internalizing problems (like anxiety and depressive symptoms) and externalizing problems (like defiance and aggressive behavior). At age 10, participants also underwent an MRI scan and those who were excessive criers as infants were found to have a smaller amygdala, a region known for being important in regulating emotions.

The authors concluded that colicky behavior in infancy may reflect some underlying temperamental vulnerabilities and may have more predictive value than previously thought. The connection between excessive crying and a measurable brain region difference later in life is also interesting, although these kinds of brain imaging findings have been notoriously difficult to interpret clinically.

Overall, this is a solid study that deserves to be considered. Colic may reflect a bit more than most of us have been taught and shouldn’t necessarily be “shrugged off,” as the authors state in their discussion.

At the same time, however, it is important not to overinterpret the findings. The magnitude of the effects were on the small side (about 0.2 of a standard deviation) and most children with excessive crying in early infancy did not manifest high levels of mental health problems later in life. The mothers of high crying infants also had slightly higher levels of mental health problems themselves so there could be other mechanisms at work here, such as genetic differences between the two groups.

So how could a pediatrician best use this new information without taking things too far? Regardless of the question of whether the excessive crying infancy is a true risk factor for later behavior problems (in the causal sense) or whether it represents more of a marker for something else, its presence so early in life offers an opportunity. Primary care clinicians would still likely want to provide the reassurance that has typically been given in these visits but perhaps with the caveat that some of these kids go on to struggle a bit more with mental health and that they might benefit from some additional support. We are not talking about prophylactic medications here, but something like additional parenting skills. Especially if you, as the pediatrician, suspect that the parents might benefit from expanding their parenting toolkit already, here is a nice opportunity to invite them to learn some new approaches and skills — framed in a way that focuses on the temperament of the child rather than any “deficits” you perceive in the parents. Some parents may be more receptive and less defensive to the idea of participating in parent training under the framework that they are doing this because they have a temperamentally more challenging child (rather than feeling that they are deficient in basic parenting skills).

It’s always a good idea to know about what resources are available in the community when it comes to teaching parenting skills. In addition to scientifically supported books and podcasts, there has been a steady increase in reliable websites, apps, and other digital platforms related to parenting, as well as standard in-person groups and classes. This could also be a great use of an integrated behavioral health professional for practices fortunate enough to have one.

In summary, there is some new evidence that colic can represent a little more than “just gas,” and while we shouldn’t take this one study to the extreme, there may be some good opportunities here to discuss and support good parenting practices in general.

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

Reference

1. Sammallahti S et al. Excessive crying, behavior problems, and amygdala volume: A study from infancy to adolescence. J Am Acad Child Adolesc Psychiatry. 2023 Jun;62(6):675-83. doi: 10.1016/j.jaac.2023.01.014.

Pediatricians commonly are asked to see infants presenting with symptoms of colic. The frequent and intense crying associated with colic is understandably quite distressing to parents, who often worry about a serious underlying medical cause. There also is the stress of trying to soothe an irritable infant who often does not seem to respond to the typical interventions.

Conventional wisdom about colic has been that the behaviors are the result of some gastrointestinal problem that, while not perfectly understood, tends to be mercifully self-limited and not predictive of future medical or mental health problems. This perspective then leads to pediatricians typically offering mainly sympathy and reassurance at these visits.

A new study,¹ however, challenges some of this traditional thinking. The data come from a remarkable longitudinal study called the Generation R Study (R being Rotterdam in the Netherlands) that has prospectively studied a group of nearly 5,000 children from before birth into adolescence. Colic symptoms were briefly assessed when infants were about 3 months old and emotional-behavioral problems have been prospectively measured at multiple time points subsequently using well-validated rating scales.

Dr. Rettew

The main finding of the study was excessive crying in infancy actually was significantly associated with higher levels of emotional-behavioral problems later in childhood and, to a lesser extent, in adolescence. This held for both internalizing problems (like anxiety and depressive symptoms) and externalizing problems (like defiance and aggressive behavior). At age 10, participants also underwent an MRI scan and those who were excessive criers as infants were found to have a smaller amygdala, a region known for being important in regulating emotions.

The authors concluded that colicky behavior in infancy may reflect some underlying temperamental vulnerabilities and may have more predictive value than previously thought. The connection between excessive crying and a measurable brain region difference later in life is also interesting, although these kinds of brain imaging findings have been notoriously difficult to interpret clinically.

Overall, this is a solid study that deserves to be considered. Colic may reflect a bit more than most of us have been taught and shouldn’t necessarily be “shrugged off,” as the authors state in their discussion.

At the same time, however, it is important not to overinterpret the findings. The magnitude of the effects were on the small side (about 0.2 of a standard deviation) and most children with excessive crying in early infancy did not manifest high levels of mental health problems later in life. The mothers of high crying infants also had slightly higher levels of mental health problems themselves so there could be other mechanisms at work here, such as genetic differences between the two groups.

So how could a pediatrician best use this new information without taking things too far? Regardless of the question of whether the excessive crying infancy is a true risk factor for later behavior problems (in the causal sense) or whether it represents more of a marker for something else, its presence so early in life offers an opportunity. Primary care clinicians would still likely want to provide the reassurance that has typically been given in these visits but perhaps with the caveat that some of these kids go on to struggle a bit more with mental health and that they might benefit from some additional support. We are not talking about prophylactic medications here, but something like additional parenting skills. Especially if you, as the pediatrician, suspect that the parents might benefit from expanding their parenting toolkit already, here is a nice opportunity to invite them to learn some new approaches and skills — framed in a way that focuses on the temperament of the child rather than any “deficits” you perceive in the parents. Some parents may be more receptive and less defensive to the idea of participating in parent training under the framework that they are doing this because they have a temperamentally more challenging child (rather than feeling that they are deficient in basic parenting skills).

It’s always a good idea to know about what resources are available in the community when it comes to teaching parenting skills. In addition to scientifically supported books and podcasts, there has been a steady increase in reliable websites, apps, and other digital platforms related to parenting, as well as standard in-person groups and classes. This could also be a great use of an integrated behavioral health professional for practices fortunate enough to have one.

In summary, there is some new evidence that colic can represent a little more than “just gas,” and while we shouldn’t take this one study to the extreme, there may be some good opportunities here to discuss and support good parenting practices in general.

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

Reference

1. Sammallahti S et al. Excessive crying, behavior problems, and amygdala volume: A study from infancy to adolescence. J Am Acad Child Adolesc Psychiatry. 2023 Jun;62(6):675-83. doi: 10.1016/j.jaac.2023.01.014.

Since 1983, when I was a child and fled as a boat refugee from Vietnam with my mother, the international plight of displaced people has only worsened. From 1997 to 2022, the number of forcibly displaced people has more than tripled, growing from 34 million to more than 108 million.¹

Displaced people are designated as refugees only when they cross international borders and meet the United Nations High Commissioner for Refugees’ (UNHCR) definition as “persons outside their countries of origin who are in need of international protection because of a serious threat to their life, physical integrity, or freedom in their country of origin as a result of persecution, armed conflict, violence, or serious public disorder.”² There is a separate mandate by the United Nations for the aid of Palestinian refugees under the United Nations General Assembly’s United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA).³ Of the displaced in 2022, more than 36 million were recognized as refugees under UNHCR and UNRWA mandates.¹ Of these, almost 50% were children, at 17.5 million.⁴ To make matters worse, worldwide children represent less than one-third of the population.⁴ Since 2022, the increase in refugeeism is mostly driven by Ukraine and Syria, though also significantly Afghanistan, Venezuela, Sudan, Myanmar, Congo, Somalia, and Central African Republic.⁴ Refugeeism is a growing problem that disproportionately impacts children through sheer number, and one suspects, given their greater overall vulnerabilities compared with adults, physical and mental health consequences.
 

Traumas of refugees compared with non-refugee immigrants

In terms of mental health, refugees are distinct from non-refugee immigrants in that they likely experience more severe psychosocial adversities from greater poverty, greater risk of family separation, and uncertainty of the asylum process.^5-8

From my own experience, this stems from the urgent nature of the refugee’s displacement, where they are often fleeing an immediate danger. My family had fled persecution from Communist forces and the social economic collapse that rendered Vietnam, for a time, one of the poorest in the world.⁹ Or, as my mother observed, “We had to leave because even doctors were starving.”

Refugees often have little preparation, have little legal protection since they are often criminalized, and are forced to endure dangerous conditions where they are vulnerable to smugglers and criminals who exploit their unprotected status. Once they arrive in their new country, they often do not have other family as social supports or resources. They themselves become the anchor for future legal and orderly immigration of their remaining family, given that they can extend their refugee status to those left behind.¹⁰ These non-refugee immigrants, unlike their refugee counterparts, are often flown to their new homes with more preparation, protecting them from dangerous conditions, and have the benefit of family who provide them with resources. As such, refugees tend to experience more traumatic life events than non-refugee immigrants. This was true in my family where those of us who initially escaped became the anchors to legally, and more safely, immigrate most of our family in Vietnam. We became their resources, likely making their acclimation smoother.
 

The mental health of refugee children and their caregivers

It is important to understand the stressors affecting the caregivers of children, since effective treatment of their mental health conditions can also benefit the children as well.¹¹ In fact, among the greatest protective factors for refugee children is the presence of an adult caregiver, suggesting that the child’s mental health is dependent on the caregivers.

Those children who are separated show much worse mental health sequalae.¹² As such, an understanding of the caregiver’s stressors is important. For example, when we were escaping Vietnam, my mom would protect me from our hardships by talking about our goals in America, minimizing our dangers by saying that we would be rewarded with things like a hamburger with its seemingly impossible amount of meat. Physically, my mother would always sleep with her arms around me and a knife hidden in order to ward off any attackers at night. When I was starving in the hull of a boat, having not eaten for days, my mother begged for food and gave me what she could get. And post-escape, my family focused on work and applied for aid for shelter and food, while encouraging us to invest in education, likely preventing involvement in criminal activities or gangs. Though overall, my family shielded me from the worst consequences, they also passed on their fears. One of my uncles had been killed by the police when he tried to escape, and so my family passed down a deep suspicion of authorities, whether they were the police or school principals. My mother had vivid memories of Communist re-education camps, which likely gave her a lasting fear that a Communist would find out our identities in America and re-capture us.
 

The mental health risk of refugees

Given that refugees tend to experience greater amounts of traumatic life events and a vast array of stressors sustained across years and even decades before, during, and after migration, it is no wonder they have much higher rates of mental health conditions, most predominantly PTSD and affective disorders.^13,14 They are at particular risk of developing psychoses because they are more likely to experience a range of physical, psychological, and psychosocial problems associated with adversities such as violence, discrimination, economic stress, and social isolation.¹³ For example, the period leading up to my escape consisted of decades of prolonged war: the French-Indochina from 1945 to 1954, then the Vietnam War from 1955 to 1975) as well as the persecution and re-education camps afterward. What my family had to endure created a period of fear and loss into which I was born into in 1976. That year, my family had lost its fortune due to the Communist government seizing of our home and business, plunging us from a comfortable middle- to upper-class life to poverty. There was also widespread fear of systematic rape by the Communist victors. So my family endured great stress and the loss of a way of life leading up to our escape.

For the refugees, the escape itself is often a dangerous journey where, given its emergent nature, they are often exposed to the elements. We know about the current situation in Ukraine and Gaza, where children are fleeing from bombs and bullets. In my situation, we endured weeks of starvation crammed in the hull of boat as we forged through the Indian Ocean to the Philippines. One of my aunts, on a separate trip, perished because her boat had capsized, like so many others. Though impossible to verify, it has been estimated that up to 70% of Vietnamese refugees died during their escape.¹⁵ After the boat, my mother and I still had to brave Malaysian jungles and prisons, and then refugee camps for a year before we reached safety at an American Embassy in the Philippines. After we gained sponsorship to America, the traumas did not abate, but were only replaced by those of culture shock, poverty, and alienation. Taken by themselves, significant traumas exist in each phase of a refugee child’s escape, whether before, during, or after. These traumas are likely compounded since they are continuously layered and sustained across years, even decades. They affect not only the children, but their parents, and sometimes even a whole nation of people.
 

Summary

In recent decades, refugeeism has been a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, or social upheavals. It is known that refugees are at greater risk for PTSD and affective and psychotic disorders, presumably due to increased traumatic life events before, during, and after their migration. The writer uses his own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.

Dr. Nguyen is a second year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.

References

1. UNHCR. Global Trends. Forced displacement in 2016. Geneva, Switzerland: The UN Refugee Agency, 2022. https://www.unhcr.org/global-trends.

2. Office of the United Nations High Commissioner for Refugees. The refugee concept under international law. Global compact for safe, orderly and regular migration.  https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf. Published March 8, 2018.

3. United Nations. (2023, November 11). The Question of Palestine. Un.org. https://www.un.org/unispal/document/un-general-assembly-renews-unrwa-mandate-press-release/

4. UNICEF. (2023, November 11). Child displacement. Data.unicef.org. https://data.unicef.org/topic/child-migration-and-displacement/displacement

5. Kinzie JD. Immigrants and refugees: The psychiatric perspective. Transcult Psychiatry. 2006 Dec;43(4):577-91. doi: 10.1177/1363461506070782.

6. Eaton W and Harrison G. Ethnic disadvantage and schizophrenia. Acta Psychiatr Scand Suppl. 2000:(407):38-43. doi: 10.1034/j.1600-0447.2000.00007.x.

7. Gilliver SC et al. Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health. 2014 Aug:24 Suppl 1:72-9. doi: 10.1093/eurpub/cku101.

8. Rapp MA et al. When local poverty is more important than your income: Mental health in minorities in inner cities. World Psychiatry. 2015 Jun;14(2):249-50. doi: 10.1002/wps.20221.

9. Cima, Ronald, ed. Vietnam: A Country Study. Washington: GPO for the Library of Congress, 1987.

10. United States Citizenship & Immigration Services (2023, November 12). Refugees. Uscis.gov. https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees

11. Fazel M and Betancourt TS. (2018). Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-32. doi: 10.1016/S2352-4642(17)30147-5.

12. Fazel M et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012 Jan 21;379(9812):266-82. doi: 10.1016/S0140-6736(11)60051-2.

13. Dapunt J et al. Refugees and psychosis: A review of the literature. Transl Psychiatry. 2017 Jun 13;7(6):e1149. doi: 10.1038/tp.2017.119.

14. Fazel M et al. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systematic review. Lancet. 2005 Apr;365(9467):1309-14. doi: 10.1016/S0140-6736(05)61027-6.

15. Rummel R. Statistics of Vietnamese Democide, in his Statistics of Democide. 1997. Table 6.1B,lines 730, 749-51.

Since 1983, when I was a child and fled as a boat refugee from Vietnam with my mother, the international plight of displaced people has only worsened. From 1997 to 2022, the number of forcibly displaced people has more than tripled, growing from 34 million to more than 108 million.¹

Displaced people are designated as refugees only when they cross international borders and meet the United Nations High Commissioner for Refugees’ (UNHCR) definition as “persons outside their countries of origin who are in need of international protection because of a serious threat to their life, physical integrity, or freedom in their country of origin as a result of persecution, armed conflict, violence, or serious public disorder.”² There is a separate mandate by the United Nations for the aid of Palestinian refugees under the United Nations General Assembly’s United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA).³ Of the displaced in 2022, more than 36 million were recognized as refugees under UNHCR and UNRWA mandates.¹ Of these, almost 50% were children, at 17.5 million.⁴ To make matters worse, worldwide children represent less than one-third of the population.⁴ Since 2022, the increase in refugeeism is mostly driven by Ukraine and Syria, though also significantly Afghanistan, Venezuela, Sudan, Myanmar, Congo, Somalia, and Central African Republic.⁴ Refugeeism is a growing problem that disproportionately impacts children through sheer number, and one suspects, given their greater overall vulnerabilities compared with adults, physical and mental health consequences.
 

Traumas of refugees compared with non-refugee immigrants

In terms of mental health, refugees are distinct from non-refugee immigrants in that they likely experience more severe psychosocial adversities from greater poverty, greater risk of family separation, and uncertainty of the asylum process.^5-8

From my own experience, this stems from the urgent nature of the refugee’s displacement, where they are often fleeing an immediate danger. My family had fled persecution from Communist forces and the social economic collapse that rendered Vietnam, for a time, one of the poorest in the world.⁹ Or, as my mother observed, “We had to leave because even doctors were starving.”

Refugees often have little preparation, have little legal protection since they are often criminalized, and are forced to endure dangerous conditions where they are vulnerable to smugglers and criminals who exploit their unprotected status. Once they arrive in their new country, they often do not have other family as social supports or resources. They themselves become the anchor for future legal and orderly immigration of their remaining family, given that they can extend their refugee status to those left behind.¹⁰ These non-refugee immigrants, unlike their refugee counterparts, are often flown to their new homes with more preparation, protecting them from dangerous conditions, and have the benefit of family who provide them with resources. As such, refugees tend to experience more traumatic life events than non-refugee immigrants. This was true in my family where those of us who initially escaped became the anchors to legally, and more safely, immigrate most of our family in Vietnam. We became their resources, likely making their acclimation smoother.
 

The mental health of refugee children and their caregivers

It is important to understand the stressors affecting the caregivers of children, since effective treatment of their mental health conditions can also benefit the children as well.¹¹ In fact, among the greatest protective factors for refugee children is the presence of an adult caregiver, suggesting that the child’s mental health is dependent on the caregivers.

Those children who are separated show much worse mental health sequalae.¹² As such, an understanding of the caregiver’s stressors is important. For example, when we were escaping Vietnam, my mom would protect me from our hardships by talking about our goals in America, minimizing our dangers by saying that we would be rewarded with things like a hamburger with its seemingly impossible amount of meat. Physically, my mother would always sleep with her arms around me and a knife hidden in order to ward off any attackers at night. When I was starving in the hull of a boat, having not eaten for days, my mother begged for food and gave me what she could get. And post-escape, my family focused on work and applied for aid for shelter and food, while encouraging us to invest in education, likely preventing involvement in criminal activities or gangs. Though overall, my family shielded me from the worst consequences, they also passed on their fears. One of my uncles had been killed by the police when he tried to escape, and so my family passed down a deep suspicion of authorities, whether they were the police or school principals. My mother had vivid memories of Communist re-education camps, which likely gave her a lasting fear that a Communist would find out our identities in America and re-capture us.
 

The mental health risk of refugees

Given that refugees tend to experience greater amounts of traumatic life events and a vast array of stressors sustained across years and even decades before, during, and after migration, it is no wonder they have much higher rates of mental health conditions, most predominantly PTSD and affective disorders.^13,14 They are at particular risk of developing psychoses because they are more likely to experience a range of physical, psychological, and psychosocial problems associated with adversities such as violence, discrimination, economic stress, and social isolation.¹³ For example, the period leading up to my escape consisted of decades of prolonged war: the French-Indochina from 1945 to 1954, then the Vietnam War from 1955 to 1975) as well as the persecution and re-education camps afterward. What my family had to endure created a period of fear and loss into which I was born into in 1976. That year, my family had lost its fortune due to the Communist government seizing of our home and business, plunging us from a comfortable middle- to upper-class life to poverty. There was also widespread fear of systematic rape by the Communist victors. So my family endured great stress and the loss of a way of life leading up to our escape.

For the refugees, the escape itself is often a dangerous journey where, given its emergent nature, they are often exposed to the elements. We know about the current situation in Ukraine and Gaza, where children are fleeing from bombs and bullets. In my situation, we endured weeks of starvation crammed in the hull of boat as we forged through the Indian Ocean to the Philippines. One of my aunts, on a separate trip, perished because her boat had capsized, like so many others. Though impossible to verify, it has been estimated that up to 70% of Vietnamese refugees died during their escape.¹⁵ After the boat, my mother and I still had to brave Malaysian jungles and prisons, and then refugee camps for a year before we reached safety at an American Embassy in the Philippines. After we gained sponsorship to America, the traumas did not abate, but were only replaced by those of culture shock, poverty, and alienation. Taken by themselves, significant traumas exist in each phase of a refugee child’s escape, whether before, during, or after. These traumas are likely compounded since they are continuously layered and sustained across years, even decades. They affect not only the children, but their parents, and sometimes even a whole nation of people.
 

Summary

In recent decades, refugeeism has been a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, or social upheavals. It is known that refugees are at greater risk for PTSD and affective and psychotic disorders, presumably due to increased traumatic life events before, during, and after their migration. The writer uses his own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.

Dr. Nguyen is a second year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.

References

1. UNHCR. Global Trends. Forced displacement in 2016. Geneva, Switzerland: The UN Refugee Agency, 2022. https://www.unhcr.org/global-trends.

2. Office of the United Nations High Commissioner for Refugees. The refugee concept under international law. Global compact for safe, orderly and regular migration.  https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf. Published March 8, 2018.

3. United Nations. (2023, November 11). The Question of Palestine. Un.org. https://www.un.org/unispal/document/un-general-assembly-renews-unrwa-mandate-press-release/

4. UNICEF. (2023, November 11). Child displacement. Data.unicef.org. https://data.unicef.org/topic/child-migration-and-displacement/displacement

5. Kinzie JD. Immigrants and refugees: The psychiatric perspective. Transcult Psychiatry. 2006 Dec;43(4):577-91. doi: 10.1177/1363461506070782.

6. Eaton W and Harrison G. Ethnic disadvantage and schizophrenia. Acta Psychiatr Scand Suppl. 2000:(407):38-43. doi: 10.1034/j.1600-0447.2000.00007.x.

7. Gilliver SC et al. Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health. 2014 Aug:24 Suppl 1:72-9. doi: 10.1093/eurpub/cku101.

8. Rapp MA et al. When local poverty is more important than your income: Mental health in minorities in inner cities. World Psychiatry. 2015 Jun;14(2):249-50. doi: 10.1002/wps.20221.

9. Cima, Ronald, ed. Vietnam: A Country Study. Washington: GPO for the Library of Congress, 1987.

10. United States Citizenship & Immigration Services (2023, November 12). Refugees. Uscis.gov. https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees

11. Fazel M and Betancourt TS. (2018). Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-32. doi: 10.1016/S2352-4642(17)30147-5.

12. Fazel M et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012 Jan 21;379(9812):266-82. doi: 10.1016/S0140-6736(11)60051-2.

13. Dapunt J et al. Refugees and psychosis: A review of the literature. Transl Psychiatry. 2017 Jun 13;7(6):e1149. doi: 10.1038/tp.2017.119.

14. Fazel M et al. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systematic review. Lancet. 2005 Apr;365(9467):1309-14. doi: 10.1016/S0140-6736(05)61027-6.

15. Rummel R. Statistics of Vietnamese Democide, in his Statistics of Democide. 1997. Table 6.1B,lines 730, 749-51.

Since 1983, when I was a child and fled as a boat refugee from Vietnam with my mother, the international plight of displaced people has only worsened. From 1997 to 2022, the number of forcibly displaced people has more than tripled, growing from 34 million to more than 108 million.¹

Displaced people are designated as refugees only when they cross international borders and meet the United Nations High Commissioner for Refugees’ (UNHCR) definition as “persons outside their countries of origin who are in need of international protection because of a serious threat to their life, physical integrity, or freedom in their country of origin as a result of persecution, armed conflict, violence, or serious public disorder.”² There is a separate mandate by the United Nations for the aid of Palestinian refugees under the United Nations General Assembly’s United Nations Relief and Works Agency for Palestinian Refugees in the Near East (UNRWA).³ Of the displaced in 2022, more than 36 million were recognized as refugees under UNHCR and UNRWA mandates.¹ Of these, almost 50% were children, at 17.5 million.⁴ To make matters worse, worldwide children represent less than one-third of the population.⁴ Since 2022, the increase in refugeeism is mostly driven by Ukraine and Syria, though also significantly Afghanistan, Venezuela, Sudan, Myanmar, Congo, Somalia, and Central African Republic.⁴ Refugeeism is a growing problem that disproportionately impacts children through sheer number, and one suspects, given their greater overall vulnerabilities compared with adults, physical and mental health consequences.
 

Traumas of refugees compared with non-refugee immigrants

In terms of mental health, refugees are distinct from non-refugee immigrants in that they likely experience more severe psychosocial adversities from greater poverty, greater risk of family separation, and uncertainty of the asylum process.^5-8

From my own experience, this stems from the urgent nature of the refugee’s displacement, where they are often fleeing an immediate danger. My family had fled persecution from Communist forces and the social economic collapse that rendered Vietnam, for a time, one of the poorest in the world.⁹ Or, as my mother observed, “We had to leave because even doctors were starving.”

Refugees often have little preparation, have little legal protection since they are often criminalized, and are forced to endure dangerous conditions where they are vulnerable to smugglers and criminals who exploit their unprotected status. Once they arrive in their new country, they often do not have other family as social supports or resources. They themselves become the anchor for future legal and orderly immigration of their remaining family, given that they can extend their refugee status to those left behind.¹⁰ These non-refugee immigrants, unlike their refugee counterparts, are often flown to their new homes with more preparation, protecting them from dangerous conditions, and have the benefit of family who provide them with resources. As such, refugees tend to experience more traumatic life events than non-refugee immigrants. This was true in my family where those of us who initially escaped became the anchors to legally, and more safely, immigrate most of our family in Vietnam. We became their resources, likely making their acclimation smoother.
 

The mental health of refugee children and their caregivers

It is important to understand the stressors affecting the caregivers of children, since effective treatment of their mental health conditions can also benefit the children as well.¹¹ In fact, among the greatest protective factors for refugee children is the presence of an adult caregiver, suggesting that the child’s mental health is dependent on the caregivers.

Those children who are separated show much worse mental health sequalae.¹² As such, an understanding of the caregiver’s stressors is important. For example, when we were escaping Vietnam, my mom would protect me from our hardships by talking about our goals in America, minimizing our dangers by saying that we would be rewarded with things like a hamburger with its seemingly impossible amount of meat. Physically, my mother would always sleep with her arms around me and a knife hidden in order to ward off any attackers at night. When I was starving in the hull of a boat, having not eaten for days, my mother begged for food and gave me what she could get. And post-escape, my family focused on work and applied for aid for shelter and food, while encouraging us to invest in education, likely preventing involvement in criminal activities or gangs. Though overall, my family shielded me from the worst consequences, they also passed on their fears. One of my uncles had been killed by the police when he tried to escape, and so my family passed down a deep suspicion of authorities, whether they were the police or school principals. My mother had vivid memories of Communist re-education camps, which likely gave her a lasting fear that a Communist would find out our identities in America and re-capture us.
 

The mental health risk of refugees

Given that refugees tend to experience greater amounts of traumatic life events and a vast array of stressors sustained across years and even decades before, during, and after migration, it is no wonder they have much higher rates of mental health conditions, most predominantly PTSD and affective disorders.^13,14 They are at particular risk of developing psychoses because they are more likely to experience a range of physical, psychological, and psychosocial problems associated with adversities such as violence, discrimination, economic stress, and social isolation.¹³ For example, the period leading up to my escape consisted of decades of prolonged war: the French-Indochina from 1945 to 1954, then the Vietnam War from 1955 to 1975) as well as the persecution and re-education camps afterward. What my family had to endure created a period of fear and loss into which I was born into in 1976. That year, my family had lost its fortune due to the Communist government seizing of our home and business, plunging us from a comfortable middle- to upper-class life to poverty. There was also widespread fear of systematic rape by the Communist victors. So my family endured great stress and the loss of a way of life leading up to our escape.

For the refugees, the escape itself is often a dangerous journey where, given its emergent nature, they are often exposed to the elements. We know about the current situation in Ukraine and Gaza, where children are fleeing from bombs and bullets. In my situation, we endured weeks of starvation crammed in the hull of boat as we forged through the Indian Ocean to the Philippines. One of my aunts, on a separate trip, perished because her boat had capsized, like so many others. Though impossible to verify, it has been estimated that up to 70% of Vietnamese refugees died during their escape.¹⁵ After the boat, my mother and I still had to brave Malaysian jungles and prisons, and then refugee camps for a year before we reached safety at an American Embassy in the Philippines. After we gained sponsorship to America, the traumas did not abate, but were only replaced by those of culture shock, poverty, and alienation. Taken by themselves, significant traumas exist in each phase of a refugee child’s escape, whether before, during, or after. These traumas are likely compounded since they are continuously layered and sustained across years, even decades. They affect not only the children, but their parents, and sometimes even a whole nation of people.
 

Summary

In recent decades, refugeeism has been a growing problem that disproportionately affects children. Refugee children and their families experience a variety of traumas, often sustained across years and even decades, because of armed conflict, persecution, or social upheavals. It is known that refugees are at greater risk for PTSD and affective and psychotic disorders, presumably due to increased traumatic life events before, during, and after their migration. The writer uses his own experience as a child refugee from Vietnam to elucidate the stressors evident in various phases of forced displacement.

Dr. Nguyen is a second year resident at UCSF Fresno Psychiatry Residency. He was a public high school English teacher for 15 years previously.

References

1. UNHCR. Global Trends. Forced displacement in 2016. Geneva, Switzerland: The UN Refugee Agency, 2022. https://www.unhcr.org/global-trends.

2. Office of the United Nations High Commissioner for Refugees. The refugee concept under international law. Global compact for safe, orderly and regular migration.  https://www.unhcr.org/sites/default/files/legacy-pdf/5aa290937.pdf. Published March 8, 2018.

3. United Nations. (2023, November 11). The Question of Palestine. Un.org. https://www.un.org/unispal/document/un-general-assembly-renews-unrwa-mandate-press-release/

4. UNICEF. (2023, November 11). Child displacement. Data.unicef.org. https://data.unicef.org/topic/child-migration-and-displacement/displacement

5. Kinzie JD. Immigrants and refugees: The psychiatric perspective. Transcult Psychiatry. 2006 Dec;43(4):577-91. doi: 10.1177/1363461506070782.

6. Eaton W and Harrison G. Ethnic disadvantage and schizophrenia. Acta Psychiatr Scand Suppl. 2000:(407):38-43. doi: 10.1034/j.1600-0447.2000.00007.x.

7. Gilliver SC et al. Recent research on the mental health of immigrants to Sweden: a literature review. Eur J Public Health. 2014 Aug:24 Suppl 1:72-9. doi: 10.1093/eurpub/cku101.

8. Rapp MA et al. When local poverty is more important than your income: Mental health in minorities in inner cities. World Psychiatry. 2015 Jun;14(2):249-50. doi: 10.1002/wps.20221.

9. Cima, Ronald, ed. Vietnam: A Country Study. Washington: GPO for the Library of Congress, 1987.

10. United States Citizenship & Immigration Services (2023, November 12). Refugees. Uscis.gov. https://www.uscis.gov/humanitarian/refugees-and-asylum/refugees

11. Fazel M and Betancourt TS. (2018). Preventive mental health interventions for refugee children and adolescents in high-income settings. Lancet Child Adolesc Health. 2018 Feb;2(2):121-32. doi: 10.1016/S2352-4642(17)30147-5.

12. Fazel M et al. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet. 2012 Jan 21;379(9812):266-82. doi: 10.1016/S0140-6736(11)60051-2.

13. Dapunt J et al. Refugees and psychosis: A review of the literature. Transl Psychiatry. 2017 Jun 13;7(6):e1149. doi: 10.1038/tp.2017.119.

14. Fazel M et al. Prevalence of serious mental disorder in 7,000 refugees resettled in western countries: a systematic review. Lancet. 2005 Apr;365(9467):1309-14. doi: 10.1016/S0140-6736(05)61027-6.

15. Rummel R. Statistics of Vietnamese Democide, in his Statistics of Democide. 1997. Table 6.1B,lines 730, 749-51.

A 16-year-old female presents for a self-identified concern around the possibility that she is experiencing an autism spectrum disorder. She relays to the developmental pediatrician that she has been learning a lot about autism on TikTok and through other social media sites, and has become strongly convinced that she meets medical criteria for this disorder.

Oregon Health & Science University (OHSU)

A careful developmental history via a detailed interview with the mother reveals normal acquisition of early developmental milestones in addition to long-standing well-modulated eye contact felt to be paired fluidly with directed affect and gestures. The teen is described as having been an engaging toddler and preschooler, without restricted interests or repetitive behaviors, and having had no major challenges in grade school with behaviors, friendships, or academics.

During the pandemic, however, the teen became quite isolated. She developed anxiety with depression, and then started having some new repetitive arm movements within the last 12-18 months. In clinic, the teen makes robustly effortful arm-waving movements, which are noted to wane when she becomes more animated and excited during conversation, and to increase when she is less distracted by conversation and more focused on the movements.

She directs affect nicely toward her mother, while avoiding looking in the direction of the examiner until later in the evaluation when she becomes more relaxed. Prosody of speech and intonation are typical, and she describes having a close group of friends with whom she spends quite a bit of time.

The Autism Diagnostic Observation Schedule (ADOS-2 module 3) is used to gather structured observations, and these social presses yield flowing social engagement with the examiner, good understanding of humor, and overall excellent verbal and nonverbal communication skills. The teen describes hypervigilance around the emotions of others, a natural ease in understanding the perspectives of others, and a quick ability to read the energy of a room. She does have some interest in some more obscure online game forums, but her friends do as well, and she otherwise does not have a history of intrusive fixations. A social history reveals past significant verbal abuse in the home by means of her father during her first 11 years of life, which is described as quite traumatic.

After careful and thoughtful consideration (recognizing the known statistics around girls assigned female at birth, as well as nonbinary individuals and minoritized groups being underdiagnosed with autism), the history and observations are not felt to be consistent with autism, but with anxiety within the context of a trauma and stressor-related disorder. Even when accounting for the possibility of “masking,” the teen still does not meet criteria for autism based on history and presentation. The habit movements are not typical of usual stereotypies or of tics (which tend to increase with excitement and tend to have a more effortless quality), and are felt to possibly be functional in origin. Upon gently sharing these conclusions with the teen, she bursts into tears, stating her friends may now accuse her of lying, as she has already been claiming to have autism online and in person at school.
 

Countering social media diagnoses

This type of scenario is becoming increasingly common, with teens turning online primarily to social media accounts to gain knowledge around various neurologic and mental health conditions. Greater normalization of neurodiversity and greater access to high-quality information about neurodevelopmental differences is certainly progress, though unfortunately some online depictions of these conditions are simply not accurate. Many adolescents are keenly searching for both their personal identity and also a community through which they might feel wholly accepted, after experiencing some level of isolation during the pandemic followed by increased social discomfort in attempting to reintegrate into school life and society. It is important to take time to understand the drive behind an adolescent’s apparent desire for a specific diagnosis, particularly if that diagnosis is not felt to be an accurate conceptualization of the teen’s presentation by a skilled professional. Connecting the teen with a good-fit therapist and working to replace excessive screen time with exercise, outdoor activities, and in-person engagement with friends and family are also crucial interventions, though they can be incredibly difficult for families to achieve given various patient-specific and societal barriers. The overlap in symptomatology among anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorders is expansive, making it understandable that young people might misjudge their personal experience of life for a neurodevelopmental disorder for which they do not truly meet criteria. Increasing access to therapists well versed in trauma-informed care is a frequently referenced need, highlighted in this case.

Another case

In contrast to the case scenario above is that of a 19-year-old female presenting for a formal autism evaluation at the urging of her father, who has had concerns around her severe “shyness” throughout her life. He is concerned that she was not able to obtain a high school diploma despite appearing to have adequate cognitive skills, is currently quite isolated, and does not appear equipped to hold a job at this time. He describes her as having been a very quiet and self-directed young child who greatly benefited from the communication and social scaffolding provided by her slightly older and neurotypical sister. She has generally not had true friends, though she had no behavioral or academic difficulties in school other than seeming aloof and unusually quiet. Atypical social approaches have become more apparent over time, as relationship navigation has become more complex with age. She is noted to have frequent stereotyped hand-to-face movements throughout the evaluation, as well as a flat affect and unusual voice quality. She speaks slowly and softly, and while she does make eye contact, it is less well modulated than would be expected. She is very focused on her cat and online interests during conversation, and tends to give stilted answers to open-ended questions. During the interview portion of the ADOS, she demonstrates little insight into friendships and reports feeling very content on her own, though is open to the idea of relationships in the future and would like to learn how to achieve connections with others. Her father reports she tends to be generally quite blunt and has difficulty understanding humor and others’ perspectives. An autism diagnosis is made with the recommendation of application to Developmental Disability Services, given impaired adaptive skills, as a means of utilizing community-based supports to facilitate eventually obtaining a high school equivalency credential, a job, healthier living habits, and comfortable social outlets.

Discussion

It is crucial for providers to be aware of nuanced presentations of autism spectrum disorders that may have been missed in early childhood when social demands are less complicated, particularly in persons identified as female at birth, nonbinary individuals, and those belonging to minority groups. It is also important to address the widely acknowledged trend of adolescents turning to social media influencers for information around neurodevelopmental conditions, at a time in their lives when social anxiety and self-awareness are generally heightened. For an adolescent, a young social media influencer may feel like a more salient and reliable source of information than an adult with various letters after their name. A respectful relationship between a teen and a thoughtful primary care provider can help gain trust to foster open conversations around their concerns, which can further help determine if a referral to a psychologist or developmental pediatrician for a formal autism assessment is truly warranted, highlighting the need for increased diagnostic capacity for such. While it is certainly important for providers to keep an open mind and to have continued awareness around the concept of late autism diagnoses, it is wise to also be aware of this recent trend among adolescents as providers seek to guide youth toward appropriate therapies and services.

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Ore. She has no conflicts of interest.

A 16-year-old female presents for a self-identified concern around the possibility that she is experiencing an autism spectrum disorder. She relays to the developmental pediatrician that she has been learning a lot about autism on TikTok and through other social media sites, and has become strongly convinced that she meets medical criteria for this disorder.

Oregon Health & Science University (OHSU)

A careful developmental history via a detailed interview with the mother reveals normal acquisition of early developmental milestones in addition to long-standing well-modulated eye contact felt to be paired fluidly with directed affect and gestures. The teen is described as having been an engaging toddler and preschooler, without restricted interests or repetitive behaviors, and having had no major challenges in grade school with behaviors, friendships, or academics.

During the pandemic, however, the teen became quite isolated. She developed anxiety with depression, and then started having some new repetitive arm movements within the last 12-18 months. In clinic, the teen makes robustly effortful arm-waving movements, which are noted to wane when she becomes more animated and excited during conversation, and to increase when she is less distracted by conversation and more focused on the movements.

She directs affect nicely toward her mother, while avoiding looking in the direction of the examiner until later in the evaluation when she becomes more relaxed. Prosody of speech and intonation are typical, and she describes having a close group of friends with whom she spends quite a bit of time.

The Autism Diagnostic Observation Schedule (ADOS-2 module 3) is used to gather structured observations, and these social presses yield flowing social engagement with the examiner, good understanding of humor, and overall excellent verbal and nonverbal communication skills. The teen describes hypervigilance around the emotions of others, a natural ease in understanding the perspectives of others, and a quick ability to read the energy of a room. She does have some interest in some more obscure online game forums, but her friends do as well, and she otherwise does not have a history of intrusive fixations. A social history reveals past significant verbal abuse in the home by means of her father during her first 11 years of life, which is described as quite traumatic.

After careful and thoughtful consideration (recognizing the known statistics around girls assigned female at birth, as well as nonbinary individuals and minoritized groups being underdiagnosed with autism), the history and observations are not felt to be consistent with autism, but with anxiety within the context of a trauma and stressor-related disorder. Even when accounting for the possibility of “masking,” the teen still does not meet criteria for autism based on history and presentation. The habit movements are not typical of usual stereotypies or of tics (which tend to increase with excitement and tend to have a more effortless quality), and are felt to possibly be functional in origin. Upon gently sharing these conclusions with the teen, she bursts into tears, stating her friends may now accuse her of lying, as she has already been claiming to have autism online and in person at school.
 

Countering social media diagnoses

This type of scenario is becoming increasingly common, with teens turning online primarily to social media accounts to gain knowledge around various neurologic and mental health conditions. Greater normalization of neurodiversity and greater access to high-quality information about neurodevelopmental differences is certainly progress, though unfortunately some online depictions of these conditions are simply not accurate. Many adolescents are keenly searching for both their personal identity and also a community through which they might feel wholly accepted, after experiencing some level of isolation during the pandemic followed by increased social discomfort in attempting to reintegrate into school life and society. It is important to take time to understand the drive behind an adolescent’s apparent desire for a specific diagnosis, particularly if that diagnosis is not felt to be an accurate conceptualization of the teen’s presentation by a skilled professional. Connecting the teen with a good-fit therapist and working to replace excessive screen time with exercise, outdoor activities, and in-person engagement with friends and family are also crucial interventions, though they can be incredibly difficult for families to achieve given various patient-specific and societal barriers. The overlap in symptomatology among anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorders is expansive, making it understandable that young people might misjudge their personal experience of life for a neurodevelopmental disorder for which they do not truly meet criteria. Increasing access to therapists well versed in trauma-informed care is a frequently referenced need, highlighted in this case.

Another case

In contrast to the case scenario above is that of a 19-year-old female presenting for a formal autism evaluation at the urging of her father, who has had concerns around her severe “shyness” throughout her life. He is concerned that she was not able to obtain a high school diploma despite appearing to have adequate cognitive skills, is currently quite isolated, and does not appear equipped to hold a job at this time. He describes her as having been a very quiet and self-directed young child who greatly benefited from the communication and social scaffolding provided by her slightly older and neurotypical sister. She has generally not had true friends, though she had no behavioral or academic difficulties in school other than seeming aloof and unusually quiet. Atypical social approaches have become more apparent over time, as relationship navigation has become more complex with age. She is noted to have frequent stereotyped hand-to-face movements throughout the evaluation, as well as a flat affect and unusual voice quality. She speaks slowly and softly, and while she does make eye contact, it is less well modulated than would be expected. She is very focused on her cat and online interests during conversation, and tends to give stilted answers to open-ended questions. During the interview portion of the ADOS, she demonstrates little insight into friendships and reports feeling very content on her own, though is open to the idea of relationships in the future and would like to learn how to achieve connections with others. Her father reports she tends to be generally quite blunt and has difficulty understanding humor and others’ perspectives. An autism diagnosis is made with the recommendation of application to Developmental Disability Services, given impaired adaptive skills, as a means of utilizing community-based supports to facilitate eventually obtaining a high school equivalency credential, a job, healthier living habits, and comfortable social outlets.

Discussion

It is crucial for providers to be aware of nuanced presentations of autism spectrum disorders that may have been missed in early childhood when social demands are less complicated, particularly in persons identified as female at birth, nonbinary individuals, and those belonging to minority groups. It is also important to address the widely acknowledged trend of adolescents turning to social media influencers for information around neurodevelopmental conditions, at a time in their lives when social anxiety and self-awareness are generally heightened. For an adolescent, a young social media influencer may feel like a more salient and reliable source of information than an adult with various letters after their name. A respectful relationship between a teen and a thoughtful primary care provider can help gain trust to foster open conversations around their concerns, which can further help determine if a referral to a psychologist or developmental pediatrician for a formal autism assessment is truly warranted, highlighting the need for increased diagnostic capacity for such. While it is certainly important for providers to keep an open mind and to have continued awareness around the concept of late autism diagnoses, it is wise to also be aware of this recent trend among adolescents as providers seek to guide youth toward appropriate therapies and services.

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Ore. She has no conflicts of interest.

A 16-year-old female presents for a self-identified concern around the possibility that she is experiencing an autism spectrum disorder. She relays to the developmental pediatrician that she has been learning a lot about autism on TikTok and through other social media sites, and has become strongly convinced that she meets medical criteria for this disorder.

Oregon Health & Science University (OHSU)

A careful developmental history via a detailed interview with the mother reveals normal acquisition of early developmental milestones in addition to long-standing well-modulated eye contact felt to be paired fluidly with directed affect and gestures. The teen is described as having been an engaging toddler and preschooler, without restricted interests or repetitive behaviors, and having had no major challenges in grade school with behaviors, friendships, or academics.

During the pandemic, however, the teen became quite isolated. She developed anxiety with depression, and then started having some new repetitive arm movements within the last 12-18 months. In clinic, the teen makes robustly effortful arm-waving movements, which are noted to wane when she becomes more animated and excited during conversation, and to increase when she is less distracted by conversation and more focused on the movements.

She directs affect nicely toward her mother, while avoiding looking in the direction of the examiner until later in the evaluation when she becomes more relaxed. Prosody of speech and intonation are typical, and she describes having a close group of friends with whom she spends quite a bit of time.

The Autism Diagnostic Observation Schedule (ADOS-2 module 3) is used to gather structured observations, and these social presses yield flowing social engagement with the examiner, good understanding of humor, and overall excellent verbal and nonverbal communication skills. The teen describes hypervigilance around the emotions of others, a natural ease in understanding the perspectives of others, and a quick ability to read the energy of a room. She does have some interest in some more obscure online game forums, but her friends do as well, and she otherwise does not have a history of intrusive fixations. A social history reveals past significant verbal abuse in the home by means of her father during her first 11 years of life, which is described as quite traumatic.

After careful and thoughtful consideration (recognizing the known statistics around girls assigned female at birth, as well as nonbinary individuals and minoritized groups being underdiagnosed with autism), the history and observations are not felt to be consistent with autism, but with anxiety within the context of a trauma and stressor-related disorder. Even when accounting for the possibility of “masking,” the teen still does not meet criteria for autism based on history and presentation. The habit movements are not typical of usual stereotypies or of tics (which tend to increase with excitement and tend to have a more effortless quality), and are felt to possibly be functional in origin. Upon gently sharing these conclusions with the teen, she bursts into tears, stating her friends may now accuse her of lying, as she has already been claiming to have autism online and in person at school.
 

Countering social media diagnoses

This type of scenario is becoming increasingly common, with teens turning online primarily to social media accounts to gain knowledge around various neurologic and mental health conditions. Greater normalization of neurodiversity and greater access to high-quality information about neurodevelopmental differences is certainly progress, though unfortunately some online depictions of these conditions are simply not accurate. Many adolescents are keenly searching for both their personal identity and also a community through which they might feel wholly accepted, after experiencing some level of isolation during the pandemic followed by increased social discomfort in attempting to reintegrate into school life and society. It is important to take time to understand the drive behind an adolescent’s apparent desire for a specific diagnosis, particularly if that diagnosis is not felt to be an accurate conceptualization of the teen’s presentation by a skilled professional. Connecting the teen with a good-fit therapist and working to replace excessive screen time with exercise, outdoor activities, and in-person engagement with friends and family are also crucial interventions, though they can be incredibly difficult for families to achieve given various patient-specific and societal barriers. The overlap in symptomatology among anxiety, attention-deficit/hyperactivity disorder, and autism spectrum disorders is expansive, making it understandable that young people might misjudge their personal experience of life for a neurodevelopmental disorder for which they do not truly meet criteria. Increasing access to therapists well versed in trauma-informed care is a frequently referenced need, highlighted in this case.

Another case

In contrast to the case scenario above is that of a 19-year-old female presenting for a formal autism evaluation at the urging of her father, who has had concerns around her severe “shyness” throughout her life. He is concerned that she was not able to obtain a high school diploma despite appearing to have adequate cognitive skills, is currently quite isolated, and does not appear equipped to hold a job at this time. He describes her as having been a very quiet and self-directed young child who greatly benefited from the communication and social scaffolding provided by her slightly older and neurotypical sister. She has generally not had true friends, though she had no behavioral or academic difficulties in school other than seeming aloof and unusually quiet. Atypical social approaches have become more apparent over time, as relationship navigation has become more complex with age. She is noted to have frequent stereotyped hand-to-face movements throughout the evaluation, as well as a flat affect and unusual voice quality. She speaks slowly and softly, and while she does make eye contact, it is less well modulated than would be expected. She is very focused on her cat and online interests during conversation, and tends to give stilted answers to open-ended questions. During the interview portion of the ADOS, she demonstrates little insight into friendships and reports feeling very content on her own, though is open to the idea of relationships in the future and would like to learn how to achieve connections with others. Her father reports she tends to be generally quite blunt and has difficulty understanding humor and others’ perspectives. An autism diagnosis is made with the recommendation of application to Developmental Disability Services, given impaired adaptive skills, as a means of utilizing community-based supports to facilitate eventually obtaining a high school equivalency credential, a job, healthier living habits, and comfortable social outlets.

Discussion

It is crucial for providers to be aware of nuanced presentations of autism spectrum disorders that may have been missed in early childhood when social demands are less complicated, particularly in persons identified as female at birth, nonbinary individuals, and those belonging to minority groups. It is also important to address the widely acknowledged trend of adolescents turning to social media influencers for information around neurodevelopmental conditions, at a time in their lives when social anxiety and self-awareness are generally heightened. For an adolescent, a young social media influencer may feel like a more salient and reliable source of information than an adult with various letters after their name. A respectful relationship between a teen and a thoughtful primary care provider can help gain trust to foster open conversations around their concerns, which can further help determine if a referral to a psychologist or developmental pediatrician for a formal autism assessment is truly warranted, highlighting the need for increased diagnostic capacity for such. While it is certainly important for providers to keep an open mind and to have continued awareness around the concept of late autism diagnoses, it is wise to also be aware of this recent trend among adolescents as providers seek to guide youth toward appropriate therapies and services.

Dr. Roth is a developmental and behavioral pediatrician in Eugene, Ore. She has no conflicts of interest.

In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.

The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.¹ Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.² Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.³ Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.

Meaningful improvement in children’s mental health will require remodeling broken systems to ensure that children are supported early, effectively, and equitably. To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
 

School-based mental health programs

Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.⁴ There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.

Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.⁵ Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
 

Increasing capacity in primary care

A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.⁶ The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.

Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
 

New service models

For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.⁷ In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.

Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
 

Conclusion

The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

References

1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.

2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.

3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.

4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.

5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.

6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.

7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.

In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.

The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.¹ Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.² Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.³ Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.

Meaningful improvement in children’s mental health will require remodeling broken systems to ensure that children are supported early, effectively, and equitably. To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
 

School-based mental health programs

Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.⁴ There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.

Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.⁵ Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
 

Increasing capacity in primary care

A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.⁶ The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.

Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
 

New service models

For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.⁷ In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.

Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
 

Conclusion

The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

References

1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.

2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.

3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.

4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.

5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.

6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.

7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.

In the wake of the COVID-19 pandemic, the American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and Children’s Hospital Association declared a national emergency in child and adolescent mental health. Additionally, the U.S. Surgeon General issued an advisory highlighting increased prevalence of mental health challenges in youth, impacts of the COVID-19 pandemic, and recommendations to address this crisis.

The pandemic required youth to isolate from peers and community supports, navigate remote learning environments, and cope with grief and loss; some 140,000 children in the United States experienced the death of a caregiver due to COVID-19.¹ Virtually every system that supports children was affected. Whereas schools have historically been a main provider of child and adolescent mental health services, delivery of many school-based mental health programs was disrupted by school closures and staffing challenges. Subgroups of children (for example, those with intellectual and developmental disabilities) were particularly affected by these disruptions to daily life, and their use of emergency services increased.² Surges in psychiatric emergency department visits among children led to increased boarding, reflecting unleveraged opportunities for early intervention. Families faced changes in child care, economic uncertainty, educational responsibilities, and increased rates of domestic violence.³ Communities of color were disproportionately affected in every way, from disease mortality to learning loss and increased school dropout rates.

Meaningful improvement in children’s mental health will require remodeling broken systems to ensure that children are supported early, effectively, and equitably. To address gaps in the system, we must leverage school-based mental health programs, bolster access to and support of primary care providers, and embrace new, innovative models.
 

School-based mental health programs

Schools may be an ideal setting for universal mental health screening and opportunities for training, leadership, and whole school interventions. There is promising evidence that school-based interventions can decrease the incidence of suicide attempts and increase help-seeking behavior in students.⁴ There has long been interest in mental health screening in schools, though it has not been widely implemented given the significant resources required to both facilitate screening and effectively serve students who need additional support. Mobile apps may be one solution to scalability of both screening and interventions, but these initiatives should only be implemented within a stakeholder-engaged, family-centered multi-tiered model of behavioral support.

Other school-based initiatives include providing advice and training to teachers and school counselors and increasing access to specialized mental health professionals, including school psychologists, social workers, nurses, and behavior support workers, as well as community-based mental health providers. The 2021 American Rescue Plan Act included $170 billion for school funding, which many schools used to hire mental health workers. The Student Mental Health Helpline Act, if passed, will create helplines to support teachers as they help students address mental health issues.⁵ Educators can be trained to identify mental health needs, addressing mild symptoms themselves and referring students requiring more specialized services. Specific training programs for educators include Classroom Well-Being Information and Strategies for Educators (WISE), Youth Mental Health First Aid, and other resources funded by the U.S. Department of Health and Human Services. In addition to educators, other non–mental health professions interfacing with youth, including other youth, parents, clergy, coaches, and other community members, can be empowered with additional behavioral health knowledge and skills.
 

Increasing capacity in primary care

A number of programs are designed to improve knowledge and skills in children’s mental health among primary care providers, such as pediatricians. In Project ECHO, a “hub” of specialists, typically at an academic medical center, provides didactic lectures and case presentations for primary care “spokes” using teleconferencing.⁶ The REACH Institute uses interactive group learning followed by ongoing coaching and case-based training.

Collaborative care models known as Child Psychiatry Access Programs (CPAPs) engage child and adolescent psychiatrists to support primary care management of psychiatric disorders. Consultations may be direct or indirect, and involve technology or in-person care. Available in most states, these models increase access to mental health care, expand the capacity of the existing workforce, and decrease stigma and inconvenience for patients. Collaborative care models have been shown to lead to improved patient and family satisfaction, reduced utilization of emergency room and inpatient hospitalizations, and improved clinical outcomes. Off-site integrated care models may additionally serve larger and more geographically dispersed populations, minimize changes to existing infrastructure, reduce travel costs for clinicians, and decrease isolation of specialists. These programs are feasible, desirable, and sustainable. There is currently no cost to patients for their primary care providers’ participation in these models, as they are supported by the state, local, or insurance payer sources in addition to federal funding. Financially sustainable models are essential to ensure equitable access to these services in the future.
 

New service models

For adolescents and young adults, integrated youth service hubs such as those that have emerged in Australia, the United Kingdom, Canada, and more recently in the United States may be particularly appealing. These hubs emphasize rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration.⁷ In addition to mental health, these “one-stop shops” offer physical health, vocational supports, and case management to support basic needs. They address a particular system gap by providing services for transition-age youth rather than cutting off at age 18, as many children’s mental health services do.

Emerging solutions to the high utilization of emergency departments for pediatric mental health needs include utilization of pediatric Crisis Stabilization Units (CSUs). CSUs are community-based, short-term outpatient units that provide immediate care to children and families experiencing a mental health crisis. The goal of CSUs is to quickly stabilize the individual – often within 72 hours – and refer that individual to available community resources. This model may also reduce police involvement in mental health crises, which may be particularly important for racialized populations.
 

Conclusion

The thoughtful implementation and stable funding of evidence-based models can help schools, the health care system, and communities more effectively support children’s mental health in the post–COVID-19 pandemic era. Only with sufficient investments in the mental health system and other systems designed to support children and families, as well as careful consideration of unintended consequences on equity-deserving populations, will we see an end to this crisis.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences; program director of the child and adolescent psychiatry fellowship; and associate medical director of the perinatal program at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

References

1. Hillis SD et al. COVID-19–Associated orphanhood and caregiver death in the United States. Pediatrics. 2021;148:e2021053760.

2. Edgcomb JB et al. Mental health‐related emergency department visits among children during the early COVID‐19 pandemic. Psychiatr Res Clin Pract. 2022;4:4-11.

3. Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: A review of current perspectives and risk factors. Child and Adolescent Psychiatry and Mental Health. 2020;4:40.

4. Gijzen MWM et al. Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders. 2022;298:408-420.

5. Newman M: H.R.5235 – 117th Congress (2021-2022): Student Mental Health Helpline Act of 2021 [Internet] 2021; [cited 2023 Jan 11] Available from: http://www.congress.gov.

6. Raney L et al. Digitally driven integrated primary care and behavioral health: How technology can expand access to effective treatment. Curr Psychiatry Rep. 2017;19:86.

7. Settipani CA et al. Key attributes of integrated community-based youth service hubs for mental health: A scoping review. Int J Ment Health Syst. 2019;13:52.

Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?

While few would argue with the foundational importance of nutrition for healthy childhood development, how to apply nutrition to mental health care becomes a much more nebulous pursuit. What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.

Yet several fundamental principles seem clear and consistent over time and across studies.

Starting early

There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.¹

Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
 

Healthy diets promote mental health

If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.² While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.² There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.

In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.³

Nutraceutical options

Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.⁴ For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.⁵

Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
 

Revisitng the case study

Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.

Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.

References

1 Vohr BR et al. Pediatrics. 2017;139:S38-49.

2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.

3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.

4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.

5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.

Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?

While few would argue with the foundational importance of nutrition for healthy childhood development, how to apply nutrition to mental health care becomes a much more nebulous pursuit. What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.

Yet several fundamental principles seem clear and consistent over time and across studies.

Starting early

There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.¹

Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
 

Healthy diets promote mental health

If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.² While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.² There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.

In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.³

Nutraceutical options

Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.⁴ For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.⁵

Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
 

Revisitng the case study

Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.

Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.

References

1 Vohr BR et al. Pediatrics. 2017;139:S38-49.

2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.

3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.

4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.

5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.

Matt was diagnosed with ADHD combined type when he was 6 years old. Given his age, the family was reluctant to try medications, but after a couple years of parenting classes and reward charts, the parents requested a stimulant. He had significant improvement in focus and impulsivity but also reduced appetite. Now at age 13, irritability and depressive symptoms have been increasing for 9 months. Skeptical of adding another medication, his parents ask whether nutrition might be an alternative tool to treat his symptoms?

While few would argue with the foundational importance of nutrition for healthy childhood development, how to apply nutrition to mental health care becomes a much more nebulous pursuit. What a healthy diet even consists of seems to be a moving target over decades and years. Trendy research, supplements, and dietary approaches proliferate alongside appealing theories of action. In the end, weighing which intervention is effective for which disorder and at what cost becomes murky.

Yet several fundamental principles seem clear and consistent over time and across studies.

Starting early

There is reliable evidence that in the perinatal environment, nutrition sets the stage for many aspects of healthy development. These effects are likely mediated variously through the hypothalamic-pituitary-adrenal axis, the trillions of gut bacteria that make up the microbiome, gene-environment interactions, and more. Maternal malnutrition and stress prenatally puts infants at risk for not only poor birth outcomes but also psychiatric challenges throughout childhood, such as ADHD, anxiety, depression, and autism.¹

Intervening in the perinatal period has long-term benefits. A first step includes assessing food security, beginning with consistent access to nutritious food. It is important to inquire about the role of food and nutrition in the family’s history and culture, as well as identifying resources to support access to affordable nutrition. This can be paired with parenting interventions, such as family meals without screens. This may require scaffolding positive conversations in high-conflict family settings (see The Family Dinner Project).
 

Healthy diets promote mental health

If food security is achieved, what is next? Clinicians can inquire about the who, what, where, when, and why of nutrition to learn about a family’s eating habits.² While randomized controlled data is very limited, both cross-sectional and longitudinal studies show that healthy diets in youth correlate with mental health – more healthy foods reducing internalizing and externalizing disorders, and more typical Western diets increasing the risk. On average, dietary interventions include higher levels of fruits and vegetables, fish, and nuts, and lower levels of processed foods.² There is not evidence that restrictive diets or fasting is appropriate or safe for youth. Additionally, involving children in getting, growing, or preparing food with gradually increasing autonomy fosters self-confidence and skill development.

In those struggling with restrictive eating disorders, food is medicine – helping those with restrictive diets to develop more balanced and adequate intake for metabolic needs. Outside of diagnosable eating disorders, weight or body mass index is less of a goal or marker when it comes to mental health. Instead, look for participation in enjoyable activities, opportunities to move and rest, and a body image that supports self-care and self-confidence (see the National Institutes of Health’s We Can! Program). Creating dissonance with cultural ideals of appearance centered on thinness can prevent future eating disorders.³

Nutraceutical options

Outside of eating disorders, specific foods and plants with health or medicinal properties – variously called nutraceuticals, phytoceuticals, or micronutrients – have emerging evidence in mental health. A 2022 expert academic consensus panel reviewed the literature to create clinical guidelines in this area.⁴ For major depression, adding omega-3 fatty acids to standard antidepressant treatment or standalone St. John’s wort have adequate evidence to recommend, while adjunctive probiotics, zinc, saffron, and curcumin have sufficient though less robust evidence. S-adenosyl methionine, vitamin D, and methyfolate showed only weak evidence for depression, while vitamin C, magnesium, creatine, N-acetylcysteine, folate, and monotherapy omega-3s do not have sufficient evidence to be recommended. For ADHD there was weak support for vitamin D, but no clear evidence for omega-3s, zinc, gingko, or acetyl L-carnitine. For anxiety, there is moderate evidence for ashwagandha and lavender in adults. A child psychiatry review suggests also trying chamomile for generalized anxiety based on the evidence in young adults, and underscores some data for N-acetylcysteine for OCD in particular.⁵

Many of these nutraceuticals exhibit small or moderate effects in a limited number of trials, with generally much less data for youth, compared with adults. While the same could be said for many on- and off-label uses of psychiatric medications for kids, clinicians would be wise to consider these highly specific nutritional interventions as items on the menu of treatment options rather than stand-alone treatments.
 

Revisitng the case study

Reflecting on Matt’s care, his pediatrician first assessed his dietary patterns, noting late-night eating and caffeine use with minimal hydration or fiber across the day. Recommendations for keeping fruit and vegetable snacks easily accessible as well as carrying a water flask are well received. They also discuss adding omega-3 fatty acids and probiotics with his morning stimulant while he awaits a referral for cognitive-behavioral therapy in order to address his depressive symptoms and minimize medication needs.

Beyond addressing food security and balanced family meals, specific interventions may be appropriate as initial treatment adjuncts for mild and some moderate mental illness. For more intense moderate to severe illness, nutritional psychiatry may be considered in combination with treatments with stronger evidence. At a community level, clinicians can help advocate for universal school meal programs to address food security, and so-called salad bar interventions to increase fruit/vegetable uptake among school-age children.

Dr. Rosenfeld is associate professor of psychiatry and pediatrics at University of Vermont and the Vermont Center for Children, Youth, and Families, both in Burlington. He has no disclosures.

References

1 Vohr BR et al. Pediatrics. 2017;139:S38-49.

2. Hosker DK et al. Child Adol Psychiatr Clin N Am. 2019;28(2):171-93.

3. Stice E et al. Int J Eat Disord. 2013;46(5):478-85.

4. Sarris J et al. World J Biol Psychiatry. 2022;23(6):424-55.

5. Simkin DR et al. Child Adolesc Psychiatric Clin N Am. 2023;32:193-216.

Over the past few years, there has been rampant misinformation regarding gender-affirming care for transgender youth. In particular, there has been confusion regarding how care is administered, and what types of care are considered at various stages of development. This primer will help you understand the developmental approach to supporting transgender youth.

Gender-affirming care is a broad term that can encapsulate many different domains: social, legal, medical, and surgical affirmation. While people generally think of medical and surgical aspects of gender-affirming care, other domains can be just as important. For example, a 2020 publication in The Lancet Public Health found that access to gender-congruent government identification documents was associated with lower odds of severe psychological distress and suicidality.¹ 

Stanford Lucille Packard Children's Hospital.

Considerations for prepubertal children

The youngest developmental stage at which a young person may seek care regarding gender diversity is the prepubertal childhood stage. Guidelines set forth by The Endocrine Society and The World Professional Association for Transgender Health make it clear that no medical or surgical interventions are considered at this developmental stage.^2,3 However, some young people may choose to pursue a “social transition.” Though this may sound like one thing, social transition can mean very different things for different people. It may include any combination of adopting a new name, pronouns, hairstyle, clothing, etc. Young people may also choose to pursue these various aspects of social transition in all settings, or sometimes only in some settings (for example, only at home if they don’t yet feel comfortable doing so at school). Research so far shows that prepubertal children who are allowed to socially transition have levels of anxiety and depression nearly indistinguishable from their cisgender peers.⁴ While some in the past have raised the question of whether a social transition increases a child’s degree of gender incongruence and thus their likelihood to “persist” in a transgender identity, research has suggested this is not the case, and that gender identity does not meaningfully differ before and after a social transition.⁵ It’s worth noting, that “desistance” of a young person’s transgender identity is generally not considered an ethical goal and that gender identity conversion efforts (that is, attempts to force transgender people to be cisgender) have been labeled unethical by the American Academy of Child & Adolescent Psychiatry.

Sadly, transgender children are victims of bullying at high rates in their schools and communities. Creating safe and affirming school and community environments can be some of the highest yield ways in which providers can support the mental health of gender-diverse youth at this stage. Gender Spectrum is an excellent nonprofit that provides resources to help families and communities with some of these nonmedical supports.

 

Early adolescence and pubertal suppression

The earliest gender-affirming medical intervention that may be considered is pubertal suppression. Pubertal suppression is achieved with gonadotropin-releasing hormone agonists. This class of medications is Food and Drug Administration approved in pediatrics for precocious puberty – a condition in which young people enter puberty much earlier than expected (sometimes as early as age 3). For that condition, the rationale is to delay puberty until the patient reaches a more developmentally normative age for puberty to begin. The rationale for pubertal suppression for adolescent gender dysphoria is somewhat similar – these medications allow for the temporary pausing of puberty, which can be particularly helpful for adolescents who are having severe negative psychological reactions to the ways in which their bodies are developing. The major advantage here is that pubertal suppression can be reversed (if the medication is stopped, endogenous puberty will proceed), whereas puberty itself cannot be easily reversed (resulting in adult transgender people needing surgery and other interventions later in life, if these changes can be fully undone at all). As with all medications, puberty blockers do carry known side effects, including falling behind on bone density (sex hormones are needed to mineralize bones). Because of this, it is generally recommended that adolescents have their bone density monitored during treatment, pursue avenues to improve bone health (for example, exercise), and either stop the puberty blocker to undergo endogenous puberty or start gender-affirming hormones (estrogen or testosterone) by around age 16. 

It is also important to note that, under current guidelines, an adolescent must first undergo a comprehensive biopsychosocial mental health evaluation prior to starting pubertal suppression to ensure the clinical team has a comprehensive understanding of the adolescent’s mental health, that all potential gender supports that are needed are put into place, and that the adolescent and their guardians have a strong understanding of the medical intervention, its risks, side effects, and potential benefits. In addition, consent must be provided by parents or legal guardians, whereas adolescents themselves provide assent. Several studies have linked access to pubertal suppression, when indicated for gender dysphoria, to improved mental health outcomes (for example, van der Miesen and colleagues, Turban and colleagues, de Vries and colleagues, and Costa and colleagues).^6-9

 

Later adolescence and gender-affirming hormones

Later in adolescence, transgender youth may be candidates for gender-affirming hormone treatment (for example, estrogen or testosterone) to induce pubertal changes that align with their gender identities. Once again, under current guidelines, a comprehensive mental health biopsychosocial evaluation must be conducted prior to initiation of these treatments. Part of this evaluation includes fertility counseling and consideration of fertility preservation (for example, oocyte or semen cryopreservation), given the potential for these medications to impact fertility. It also involves discussion of several of the physiologic changes from these medications that can be irreversible (for example, voice changes from testosterone are particularly difficult to reverse in the future). Tables of the physical changes from these medications, when they begin after starting, and when they generally reach their maximum are available in the Endocrine Society guidelines.² The past endocrine society guidelines recommended not initiating gender-affirming hormones until age 16. The most recent guidelines note that there may be instances in which providers may consider starting them as early as age 13 (for example, to reduce risk of falling behind on bone density, or if a patient is having psychological distress related to their peers going through puberty while they are still in a prepubertal state). The latest World Professional Association for Transgender Health Standards of Care removed specific age cutoffs, highlighting the importance of a multidisciplinary team of mental health and hormone prescribing providers working together to understand the best course of action for a particular patient. As with pubertal suppression, several studies have linked access to gender-affirming hormones to improve mental health for adolescents with gender dysphoria (for example, Turban and colleagues, Chen and colleagues, de Vries and colleagues, Allen and colleagues, and Tordoff and colleagues).^10-14

Gender-affirming surgeries

The vast majority of gender-affirming surgeries are not considered until adulthood. The most notable exception to this is masculinizing top surgery for trans masculine and nonbinary adolescents. As with all surgeries, this is a major decision, and requires agreement from a mental health provider, a medical provider, and the surgeon. Early research suggests such surgeries result in improved chest dysphoria and that regret rates appear to be low.^15,16 While the latest World Professional Association for Transgender Health similarly removed strict age cutoffs for gender-affirming surgery, again noting the importance of individualized care, I suspect most will read this change in the context of the Endocrine Society guidelines and past WPATH guidelines that noted gender-affirming genital surgeries are not offered until adulthood (a rare exception perhaps being someone pursuing a gender-affirming vaginoplasty at say age 17 in the summer prior to college to avoid needing to take off from school for surgical recovery). Gender-affirming genital surgeries are generally much more involved surgeries with prolonged recovery times. 

Given the substantial proportion of young people who openly identify as transgender,¹⁷ and the proliferation of misinformation, political rhetoric, and legislation that can impact gender-affirming care for adolescents with gender dysphoria,¹⁸ it is essential that providers have accurate, up-to-date information on what this care entails and how it is provided.

Dr. Turban is director of the gender psychiatry program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on Twitter @jack_turban.
 

References

1. Malta M et al. Lancet Public Health. 2020 Apr;5(4):e178-9.

2. Hembree WC et al. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

3. Coleman E et al. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-259.

4. Durwood L et al. J Am Acad Child Adolesc Psychiatry. 2017 Feb;56(2):116-23.e2.

5. Rae JR et al. Psychol Sci. 2019 May;30(5):669-81.

6. van der Miesen AIR et al. J Adolesc Health. 2020 Jun;66(6):699-704.

7. Turban JL et al. Pediatrics. 2020 Feb;145(2):e20191725.

8. de Vries ALC et al. J Sex Med. 2011 Aug;8(8):2276-83.

9. Costa R et al. J Sex Med. 2015 Nov;12(11):2206-14.

10. Turban JL et al. PLoS One. 2022 Jan 12;17(1):e0261039.

11. Chen D et al. N Engl J Med. 2023;388:240-50.

12. de Vries ALC et al. Pediatrics. 2014 Oct;134(4):696-70.

13. Allen LR et al. Clin Pract Pediatr Psychol. 2019. doi: 10.1037/cpp0000288.

14. Tordoff DM et al. JAMA Netw Open. 2022 Feb 1;5(2):e220978.

15. Olson-Kennedy J et al. JAMA Pediatr. 2018;172(5):431-6.

16. Tang A et al. Ann Plast Surg. 2022 May;88(4 Suppl):S325-31

17. Johns MM et al. Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.

18. Turban JL et al. JAMA. 2021;325(22):2251-2.

Over the past few years, there has been rampant misinformation regarding gender-affirming care for transgender youth. In particular, there has been confusion regarding how care is administered, and what types of care are considered at various stages of development. This primer will help you understand the developmental approach to supporting transgender youth.

Gender-affirming care is a broad term that can encapsulate many different domains: social, legal, medical, and surgical affirmation. While people generally think of medical and surgical aspects of gender-affirming care, other domains can be just as important. For example, a 2020 publication in The Lancet Public Health found that access to gender-congruent government identification documents was associated with lower odds of severe psychological distress and suicidality.¹ 

Stanford Lucille Packard Children's Hospital.

Considerations for prepubertal children

The youngest developmental stage at which a young person may seek care regarding gender diversity is the prepubertal childhood stage. Guidelines set forth by The Endocrine Society and The World Professional Association for Transgender Health make it clear that no medical or surgical interventions are considered at this developmental stage.^2,3 However, some young people may choose to pursue a “social transition.” Though this may sound like one thing, social transition can mean very different things for different people. It may include any combination of adopting a new name, pronouns, hairstyle, clothing, etc. Young people may also choose to pursue these various aspects of social transition in all settings, or sometimes only in some settings (for example, only at home if they don’t yet feel comfortable doing so at school). Research so far shows that prepubertal children who are allowed to socially transition have levels of anxiety and depression nearly indistinguishable from their cisgender peers.⁴ While some in the past have raised the question of whether a social transition increases a child’s degree of gender incongruence and thus their likelihood to “persist” in a transgender identity, research has suggested this is not the case, and that gender identity does not meaningfully differ before and after a social transition.⁵ It’s worth noting, that “desistance” of a young person’s transgender identity is generally not considered an ethical goal and that gender identity conversion efforts (that is, attempts to force transgender people to be cisgender) have been labeled unethical by the American Academy of Child & Adolescent Psychiatry.

Sadly, transgender children are victims of bullying at high rates in their schools and communities. Creating safe and affirming school and community environments can be some of the highest yield ways in which providers can support the mental health of gender-diverse youth at this stage. Gender Spectrum is an excellent nonprofit that provides resources to help families and communities with some of these nonmedical supports.

 

Early adolescence and pubertal suppression

The earliest gender-affirming medical intervention that may be considered is pubertal suppression. Pubertal suppression is achieved with gonadotropin-releasing hormone agonists. This class of medications is Food and Drug Administration approved in pediatrics for precocious puberty – a condition in which young people enter puberty much earlier than expected (sometimes as early as age 3). For that condition, the rationale is to delay puberty until the patient reaches a more developmentally normative age for puberty to begin. The rationale for pubertal suppression for adolescent gender dysphoria is somewhat similar – these medications allow for the temporary pausing of puberty, which can be particularly helpful for adolescents who are having severe negative psychological reactions to the ways in which their bodies are developing. The major advantage here is that pubertal suppression can be reversed (if the medication is stopped, endogenous puberty will proceed), whereas puberty itself cannot be easily reversed (resulting in adult transgender people needing surgery and other interventions later in life, if these changes can be fully undone at all). As with all medications, puberty blockers do carry known side effects, including falling behind on bone density (sex hormones are needed to mineralize bones). Because of this, it is generally recommended that adolescents have their bone density monitored during treatment, pursue avenues to improve bone health (for example, exercise), and either stop the puberty blocker to undergo endogenous puberty or start gender-affirming hormones (estrogen or testosterone) by around age 16. 

It is also important to note that, under current guidelines, an adolescent must first undergo a comprehensive biopsychosocial mental health evaluation prior to starting pubertal suppression to ensure the clinical team has a comprehensive understanding of the adolescent’s mental health, that all potential gender supports that are needed are put into place, and that the adolescent and their guardians have a strong understanding of the medical intervention, its risks, side effects, and potential benefits. In addition, consent must be provided by parents or legal guardians, whereas adolescents themselves provide assent. Several studies have linked access to pubertal suppression, when indicated for gender dysphoria, to improved mental health outcomes (for example, van der Miesen and colleagues, Turban and colleagues, de Vries and colleagues, and Costa and colleagues).^6-9

 

Later adolescence and gender-affirming hormones

Later in adolescence, transgender youth may be candidates for gender-affirming hormone treatment (for example, estrogen or testosterone) to induce pubertal changes that align with their gender identities. Once again, under current guidelines, a comprehensive mental health biopsychosocial evaluation must be conducted prior to initiation of these treatments. Part of this evaluation includes fertility counseling and consideration of fertility preservation (for example, oocyte or semen cryopreservation), given the potential for these medications to impact fertility. It also involves discussion of several of the physiologic changes from these medications that can be irreversible (for example, voice changes from testosterone are particularly difficult to reverse in the future). Tables of the physical changes from these medications, when they begin after starting, and when they generally reach their maximum are available in the Endocrine Society guidelines.² The past endocrine society guidelines recommended not initiating gender-affirming hormones until age 16. The most recent guidelines note that there may be instances in which providers may consider starting them as early as age 13 (for example, to reduce risk of falling behind on bone density, or if a patient is having psychological distress related to their peers going through puberty while they are still in a prepubertal state). The latest World Professional Association for Transgender Health Standards of Care removed specific age cutoffs, highlighting the importance of a multidisciplinary team of mental health and hormone prescribing providers working together to understand the best course of action for a particular patient. As with pubertal suppression, several studies have linked access to gender-affirming hormones to improve mental health for adolescents with gender dysphoria (for example, Turban and colleagues, Chen and colleagues, de Vries and colleagues, Allen and colleagues, and Tordoff and colleagues).^10-14

Gender-affirming surgeries

The vast majority of gender-affirming surgeries are not considered until adulthood. The most notable exception to this is masculinizing top surgery for trans masculine and nonbinary adolescents. As with all surgeries, this is a major decision, and requires agreement from a mental health provider, a medical provider, and the surgeon. Early research suggests such surgeries result in improved chest dysphoria and that regret rates appear to be low.^15,16 While the latest World Professional Association for Transgender Health similarly removed strict age cutoffs for gender-affirming surgery, again noting the importance of individualized care, I suspect most will read this change in the context of the Endocrine Society guidelines and past WPATH guidelines that noted gender-affirming genital surgeries are not offered until adulthood (a rare exception perhaps being someone pursuing a gender-affirming vaginoplasty at say age 17 in the summer prior to college to avoid needing to take off from school for surgical recovery). Gender-affirming genital surgeries are generally much more involved surgeries with prolonged recovery times. 

Given the substantial proportion of young people who openly identify as transgender,¹⁷ and the proliferation of misinformation, political rhetoric, and legislation that can impact gender-affirming care for adolescents with gender dysphoria,¹⁸ it is essential that providers have accurate, up-to-date information on what this care entails and how it is provided.

Dr. Turban is director of the gender psychiatry program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on Twitter @jack_turban.
 

References

1. Malta M et al. Lancet Public Health. 2020 Apr;5(4):e178-9.

2. Hembree WC et al. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

3. Coleman E et al. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-259.

4. Durwood L et al. J Am Acad Child Adolesc Psychiatry. 2017 Feb;56(2):116-23.e2.

5. Rae JR et al. Psychol Sci. 2019 May;30(5):669-81.

6. van der Miesen AIR et al. J Adolesc Health. 2020 Jun;66(6):699-704.

7. Turban JL et al. Pediatrics. 2020 Feb;145(2):e20191725.

8. de Vries ALC et al. J Sex Med. 2011 Aug;8(8):2276-83.

9. Costa R et al. J Sex Med. 2015 Nov;12(11):2206-14.

10. Turban JL et al. PLoS One. 2022 Jan 12;17(1):e0261039.

11. Chen D et al. N Engl J Med. 2023;388:240-50.

12. de Vries ALC et al. Pediatrics. 2014 Oct;134(4):696-70.

13. Allen LR et al. Clin Pract Pediatr Psychol. 2019. doi: 10.1037/cpp0000288.

14. Tordoff DM et al. JAMA Netw Open. 2022 Feb 1;5(2):e220978.

15. Olson-Kennedy J et al. JAMA Pediatr. 2018;172(5):431-6.

16. Tang A et al. Ann Plast Surg. 2022 May;88(4 Suppl):S325-31

17. Johns MM et al. Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.

18. Turban JL et al. JAMA. 2021;325(22):2251-2.

Over the past few years, there has been rampant misinformation regarding gender-affirming care for transgender youth. In particular, there has been confusion regarding how care is administered, and what types of care are considered at various stages of development. This primer will help you understand the developmental approach to supporting transgender youth.

Gender-affirming care is a broad term that can encapsulate many different domains: social, legal, medical, and surgical affirmation. While people generally think of medical and surgical aspects of gender-affirming care, other domains can be just as important. For example, a 2020 publication in The Lancet Public Health found that access to gender-congruent government identification documents was associated with lower odds of severe psychological distress and suicidality.¹ 

Stanford Lucille Packard Children's Hospital.

Considerations for prepubertal children

The youngest developmental stage at which a young person may seek care regarding gender diversity is the prepubertal childhood stage. Guidelines set forth by The Endocrine Society and The World Professional Association for Transgender Health make it clear that no medical or surgical interventions are considered at this developmental stage.^2,3 However, some young people may choose to pursue a “social transition.” Though this may sound like one thing, social transition can mean very different things for different people. It may include any combination of adopting a new name, pronouns, hairstyle, clothing, etc. Young people may also choose to pursue these various aspects of social transition in all settings, or sometimes only in some settings (for example, only at home if they don’t yet feel comfortable doing so at school). Research so far shows that prepubertal children who are allowed to socially transition have levels of anxiety and depression nearly indistinguishable from their cisgender peers.⁴ While some in the past have raised the question of whether a social transition increases a child’s degree of gender incongruence and thus their likelihood to “persist” in a transgender identity, research has suggested this is not the case, and that gender identity does not meaningfully differ before and after a social transition.⁵ It’s worth noting, that “desistance” of a young person’s transgender identity is generally not considered an ethical goal and that gender identity conversion efforts (that is, attempts to force transgender people to be cisgender) have been labeled unethical by the American Academy of Child & Adolescent Psychiatry.

Sadly, transgender children are victims of bullying at high rates in their schools and communities. Creating safe and affirming school and community environments can be some of the highest yield ways in which providers can support the mental health of gender-diverse youth at this stage. Gender Spectrum is an excellent nonprofit that provides resources to help families and communities with some of these nonmedical supports.

 

Early adolescence and pubertal suppression

The earliest gender-affirming medical intervention that may be considered is pubertal suppression. Pubertal suppression is achieved with gonadotropin-releasing hormone agonists. This class of medications is Food and Drug Administration approved in pediatrics for precocious puberty – a condition in which young people enter puberty much earlier than expected (sometimes as early as age 3). For that condition, the rationale is to delay puberty until the patient reaches a more developmentally normative age for puberty to begin. The rationale for pubertal suppression for adolescent gender dysphoria is somewhat similar – these medications allow for the temporary pausing of puberty, which can be particularly helpful for adolescents who are having severe negative psychological reactions to the ways in which their bodies are developing. The major advantage here is that pubertal suppression can be reversed (if the medication is stopped, endogenous puberty will proceed), whereas puberty itself cannot be easily reversed (resulting in adult transgender people needing surgery and other interventions later in life, if these changes can be fully undone at all). As with all medications, puberty blockers do carry known side effects, including falling behind on bone density (sex hormones are needed to mineralize bones). Because of this, it is generally recommended that adolescents have their bone density monitored during treatment, pursue avenues to improve bone health (for example, exercise), and either stop the puberty blocker to undergo endogenous puberty or start gender-affirming hormones (estrogen or testosterone) by around age 16. 

It is also important to note that, under current guidelines, an adolescent must first undergo a comprehensive biopsychosocial mental health evaluation prior to starting pubertal suppression to ensure the clinical team has a comprehensive understanding of the adolescent’s mental health, that all potential gender supports that are needed are put into place, and that the adolescent and their guardians have a strong understanding of the medical intervention, its risks, side effects, and potential benefits. In addition, consent must be provided by parents or legal guardians, whereas adolescents themselves provide assent. Several studies have linked access to pubertal suppression, when indicated for gender dysphoria, to improved mental health outcomes (for example, van der Miesen and colleagues, Turban and colleagues, de Vries and colleagues, and Costa and colleagues).^6-9

 

Later adolescence and gender-affirming hormones

Later in adolescence, transgender youth may be candidates for gender-affirming hormone treatment (for example, estrogen or testosterone) to induce pubertal changes that align with their gender identities. Once again, under current guidelines, a comprehensive mental health biopsychosocial evaluation must be conducted prior to initiation of these treatments. Part of this evaluation includes fertility counseling and consideration of fertility preservation (for example, oocyte or semen cryopreservation), given the potential for these medications to impact fertility. It also involves discussion of several of the physiologic changes from these medications that can be irreversible (for example, voice changes from testosterone are particularly difficult to reverse in the future). Tables of the physical changes from these medications, when they begin after starting, and when they generally reach their maximum are available in the Endocrine Society guidelines.² The past endocrine society guidelines recommended not initiating gender-affirming hormones until age 16. The most recent guidelines note that there may be instances in which providers may consider starting them as early as age 13 (for example, to reduce risk of falling behind on bone density, or if a patient is having psychological distress related to their peers going through puberty while they are still in a prepubertal state). The latest World Professional Association for Transgender Health Standards of Care removed specific age cutoffs, highlighting the importance of a multidisciplinary team of mental health and hormone prescribing providers working together to understand the best course of action for a particular patient. As with pubertal suppression, several studies have linked access to gender-affirming hormones to improve mental health for adolescents with gender dysphoria (for example, Turban and colleagues, Chen and colleagues, de Vries and colleagues, Allen and colleagues, and Tordoff and colleagues).^10-14

Gender-affirming surgeries

The vast majority of gender-affirming surgeries are not considered until adulthood. The most notable exception to this is masculinizing top surgery for trans masculine and nonbinary adolescents. As with all surgeries, this is a major decision, and requires agreement from a mental health provider, a medical provider, and the surgeon. Early research suggests such surgeries result in improved chest dysphoria and that regret rates appear to be low.^15,16 While the latest World Professional Association for Transgender Health similarly removed strict age cutoffs for gender-affirming surgery, again noting the importance of individualized care, I suspect most will read this change in the context of the Endocrine Society guidelines and past WPATH guidelines that noted gender-affirming genital surgeries are not offered until adulthood (a rare exception perhaps being someone pursuing a gender-affirming vaginoplasty at say age 17 in the summer prior to college to avoid needing to take off from school for surgical recovery). Gender-affirming genital surgeries are generally much more involved surgeries with prolonged recovery times. 

Given the substantial proportion of young people who openly identify as transgender,¹⁷ and the proliferation of misinformation, political rhetoric, and legislation that can impact gender-affirming care for adolescents with gender dysphoria,¹⁸ it is essential that providers have accurate, up-to-date information on what this care entails and how it is provided.

Dr. Turban is director of the gender psychiatry program at the University of California, San Francisco, where he is an assistant professor of child & adolescent psychiatry and affiliate faculty at the Philip R. Lee Institute for Health Policy Studies. He is on Twitter @jack_turban.
 

References

1. Malta M et al. Lancet Public Health. 2020 Apr;5(4):e178-9.

2. Hembree WC et al. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.

3. Coleman E et al. Int J Transgend Health. 2022 Sep 6;23(Suppl 1):S1-259.

4. Durwood L et al. J Am Acad Child Adolesc Psychiatry. 2017 Feb;56(2):116-23.e2.

5. Rae JR et al. Psychol Sci. 2019 May;30(5):669-81.

6. van der Miesen AIR et al. J Adolesc Health. 2020 Jun;66(6):699-704.

7. Turban JL et al. Pediatrics. 2020 Feb;145(2):e20191725.

8. de Vries ALC et al. J Sex Med. 2011 Aug;8(8):2276-83.

9. Costa R et al. J Sex Med. 2015 Nov;12(11):2206-14.

10. Turban JL et al. PLoS One. 2022 Jan 12;17(1):e0261039.

11. Chen D et al. N Engl J Med. 2023;388:240-50.

12. de Vries ALC et al. Pediatrics. 2014 Oct;134(4):696-70.

13. Allen LR et al. Clin Pract Pediatr Psychol. 2019. doi: 10.1037/cpp0000288.

14. Tordoff DM et al. JAMA Netw Open. 2022 Feb 1;5(2):e220978.

15. Olson-Kennedy J et al. JAMA Pediatr. 2018;172(5):431-6.

16. Tang A et al. Ann Plast Surg. 2022 May;88(4 Suppl):S325-31

17. Johns MM et al. Morb Mortal Wkly Rep. 2019 Jan 25;68(3):67-71.

18. Turban JL et al. JAMA. 2021;325(22):2251-2.

That mantra echoed through my postgraduate medical training, and is shared with patients to encourage reaching out for help. But providers are often in the exam room alone with patients whom they are, legitimately, very worried about.

Margaret Spottswood

Dr. Rettew’s column last month detailed the systems that are changing (slowly!) to better facilitate interface between mental health and primary care. There are increasingly supports available at a clinic level, and also a state level. Regardless of where your practice is in the process of integration, there are some key resources available now that can be used by child psychiatrists and pediatricians alike. This moment in time seems like a great opportunity to review a few favorites.
 

Who you gonna call?

Child Psychiatry Access Programs, sometimes called Psychiatry Access Lines, are almost everywhere!¹ If you haven’t called one yet, click on your state and call! You will have immediate access to mental health resources that are curated and available in your state, child psychiatry expertise, and a way to connect families in need with targeted treatments. A long-term side effect of CPAP utilization may include improved system coordination on behalf of kids.

What about screening?

The AAP has an excellent mental health minute on screening.² Pediatricians screen thoughtfully for psychosocial and medical concerns. Primary and secondary screenings for mental health are becoming ubiquitous in practices as a first step toward diagnosis and treatment. Primary, or initial, screening can catch concerns in your patient population. These include common tools like the Strengths and Difficulties Questionnaire (SDQ, ages 2-17), or the Pediatric Symptom Checklist (PSC-14, ages 4-17). Subscale scores help point care toward the right direction.

Once we know there is a mental health problem through screening or interview, secondary mental health screening and rating scales help find a specific diagnosis. Some basics include the PHQ-A for depression (ages 11-17), the GAD-7 for general anxiety (ages 11+), the SCARED for specific anxiety (ages 8-18), and the Vanderbilt (ages 6+) or SNAP-IV (ages 5+) parent/teacher scales for ADHD/ODD/CD/anxiety/depressive symptoms. The CY-BOCS symptom checklist (ages 6-17) is excellent to determine the extent of OCD symptoms. The asQ (ages 10+) and Columbia (C-SSRS, ages 11+) are must-use screeners to help prevent suicide. Screeners and rating scales are found on many CPAP websites, such as New York’s.³ A site full of these can seem overwhelming, but once you get comfortable with a few favorites, expanding your repertoire little by little makes providing care a lot easier!
 

Treating to target?

When you are fairly certain of the diagnosis, you can feel more confident to treat. Diagnoses can be tools; find the best fit one, and in a few years with more information, a different tool might be a better fit.

Some favorite treatment resources include the CPAP guidebook from your state (for example, Washington’s⁴ and Virginia’s⁵), and the AACAP parent medication guides.⁶ They detail evidence-based treatments including medications, and can help us professionals and high health care–literacy families. The medication tracking form found at the back of each guide is especially key. Another great book is the DSM 5 Pocket Guide for Child and Adolescent Mental Health.⁷ Some screeners can be repeated to see if treatment is working, as the AIMS model suggests “treat to target”⁸ specific symptoms until they improve.
 

How to provide help with few resources?

There is knowing what your patient needs, like a specific therapy, and then there is the challenge of connecting the patient with help. Getting a family started on a first step of treatment while they are on a waiting list can be transformative. One example is treatment for oppositional defiant disorder (ODD); parents can start with the first step, “special time,”⁹ even before a therapist is available. Or, if a family is struggling with OCD, they can start an Exposure Therapy with Response Prevention (ERP) workbook¹⁰ or look at the iocdf.org website before seeing a specialized therapist. We all know how unsatisfactory a wait-list is as a treatment plan; it is so empowering to start the family with first steps.

What about connections for us providers?

Leveraging your own relationship with patients who have mental health challenges can be powerful, and staying connected with others is vital to maintaining your own emotional well-being. Having a therapist, being active in your medical chapters, gardening, and connecting your practice to local mental health providers and schools can be rejuvenating. Improving the systems around us prevents burnout and keeps us connected.

And finally ...

So, join the movement to help our fields work better together; walk out of that exam room and listen to your worry about your patients and the systems that support them. Reach out for help, toward child psychiatry access lines, the AAP, AACAP, and other collective agents of change. Share what is making your lives and your patients’ lives easier so we can amplify these together. Let’s worry together, and make things better.

Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt., a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont, Burlington.

References

1. National Network of Child Psychiatry Access Programs. Child Psychiatry Access Programs in the United States. https://www.nncpap.orgmap. 2023 Mar 14.

2. American Academy of Pediatrics. Screening Tools: Pediatric Mental Health Minute Series. https://www.aap.org/en/patient-care/mental-health-minute/screening-tools.

3. New York ProjectTEACH. Child Clinical Rating Scales. https://projectteachny.org/child-rating-scales.

4. Hilt H, Barclay R. Seattle Children’s Primary Care Principles for Child Mental Health. https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf.

5. Virginia Mental Health Access Program. VMAP Guidebook. https://vmap.org/guidebook.

6. American Academy of Child and Adolescent Psychiatry. Parents’ Medication Guides. https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx.

7. Hilt RJ, Nussbaum AM. DSM-5 Pocket Guide to Child and Adolescent Mental Health. Arlington, Va.: American Psychiatric Association Publishing, 2015.

8. Advanced Integration Mental Health Solutions. Measurement-Based Treatment to Target. https://aims.uw.edu/resource-library/measurement-based-treatment-target.

9. Vermont Child Psychiatry Access Program. Caregiver Guide: Special Time With Children. https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf.

10. Reuter T. Standing Up to OCD Workbook for Kids. New York: Simon and Schuster, 2019.

That mantra echoed through my postgraduate medical training, and is shared with patients to encourage reaching out for help. But providers are often in the exam room alone with patients whom they are, legitimately, very worried about.

Margaret Spottswood

Dr. Rettew’s column last month detailed the systems that are changing (slowly!) to better facilitate interface between mental health and primary care. There are increasingly supports available at a clinic level, and also a state level. Regardless of where your practice is in the process of integration, there are some key resources available now that can be used by child psychiatrists and pediatricians alike. This moment in time seems like a great opportunity to review a few favorites.
 

Who you gonna call?

Child Psychiatry Access Programs, sometimes called Psychiatry Access Lines, are almost everywhere!¹ If you haven’t called one yet, click on your state and call! You will have immediate access to mental health resources that are curated and available in your state, child psychiatry expertise, and a way to connect families in need with targeted treatments. A long-term side effect of CPAP utilization may include improved system coordination on behalf of kids.

What about screening?

The AAP has an excellent mental health minute on screening.² Pediatricians screen thoughtfully for psychosocial and medical concerns. Primary and secondary screenings for mental health are becoming ubiquitous in practices as a first step toward diagnosis and treatment. Primary, or initial, screening can catch concerns in your patient population. These include common tools like the Strengths and Difficulties Questionnaire (SDQ, ages 2-17), or the Pediatric Symptom Checklist (PSC-14, ages 4-17). Subscale scores help point care toward the right direction.

Once we know there is a mental health problem through screening or interview, secondary mental health screening and rating scales help find a specific diagnosis. Some basics include the PHQ-A for depression (ages 11-17), the GAD-7 for general anxiety (ages 11+), the SCARED for specific anxiety (ages 8-18), and the Vanderbilt (ages 6+) or SNAP-IV (ages 5+) parent/teacher scales for ADHD/ODD/CD/anxiety/depressive symptoms. The CY-BOCS symptom checklist (ages 6-17) is excellent to determine the extent of OCD symptoms. The asQ (ages 10+) and Columbia (C-SSRS, ages 11+) are must-use screeners to help prevent suicide. Screeners and rating scales are found on many CPAP websites, such as New York’s.³ A site full of these can seem overwhelming, but once you get comfortable with a few favorites, expanding your repertoire little by little makes providing care a lot easier!
 

Treating to target?

When you are fairly certain of the diagnosis, you can feel more confident to treat. Diagnoses can be tools; find the best fit one, and in a few years with more information, a different tool might be a better fit.

Some favorite treatment resources include the CPAP guidebook from your state (for example, Washington’s⁴ and Virginia’s⁵), and the AACAP parent medication guides.⁶ They detail evidence-based treatments including medications, and can help us professionals and high health care–literacy families. The medication tracking form found at the back of each guide is especially key. Another great book is the DSM 5 Pocket Guide for Child and Adolescent Mental Health.⁷ Some screeners can be repeated to see if treatment is working, as the AIMS model suggests “treat to target”⁸ specific symptoms until they improve.
 

How to provide help with few resources?

There is knowing what your patient needs, like a specific therapy, and then there is the challenge of connecting the patient with help. Getting a family started on a first step of treatment while they are on a waiting list can be transformative. One example is treatment for oppositional defiant disorder (ODD); parents can start with the first step, “special time,”⁹ even before a therapist is available. Or, if a family is struggling with OCD, they can start an Exposure Therapy with Response Prevention (ERP) workbook¹⁰ or look at the iocdf.org website before seeing a specialized therapist. We all know how unsatisfactory a wait-list is as a treatment plan; it is so empowering to start the family with first steps.

What about connections for us providers?

Leveraging your own relationship with patients who have mental health challenges can be powerful, and staying connected with others is vital to maintaining your own emotional well-being. Having a therapist, being active in your medical chapters, gardening, and connecting your practice to local mental health providers and schools can be rejuvenating. Improving the systems around us prevents burnout and keeps us connected.

And finally ...

So, join the movement to help our fields work better together; walk out of that exam room and listen to your worry about your patients and the systems that support them. Reach out for help, toward child psychiatry access lines, the AAP, AACAP, and other collective agents of change. Share what is making your lives and your patients’ lives easier so we can amplify these together. Let’s worry together, and make things better.

Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt., a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont, Burlington.

References

1. National Network of Child Psychiatry Access Programs. Child Psychiatry Access Programs in the United States. https://www.nncpap.orgmap. 2023 Mar 14.

2. American Academy of Pediatrics. Screening Tools: Pediatric Mental Health Minute Series. https://www.aap.org/en/patient-care/mental-health-minute/screening-tools.

3. New York ProjectTEACH. Child Clinical Rating Scales. https://projectteachny.org/child-rating-scales.

4. Hilt H, Barclay R. Seattle Children’s Primary Care Principles for Child Mental Health. https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf.

5. Virginia Mental Health Access Program. VMAP Guidebook. https://vmap.org/guidebook.

6. American Academy of Child and Adolescent Psychiatry. Parents’ Medication Guides. https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx.

7. Hilt RJ, Nussbaum AM. DSM-5 Pocket Guide to Child and Adolescent Mental Health. Arlington, Va.: American Psychiatric Association Publishing, 2015.

8. Advanced Integration Mental Health Solutions. Measurement-Based Treatment to Target. https://aims.uw.edu/resource-library/measurement-based-treatment-target.

9. Vermont Child Psychiatry Access Program. Caregiver Guide: Special Time With Children. https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf.

10. Reuter T. Standing Up to OCD Workbook for Kids. New York: Simon and Schuster, 2019.

That mantra echoed through my postgraduate medical training, and is shared with patients to encourage reaching out for help. But providers are often in the exam room alone with patients whom they are, legitimately, very worried about.

Margaret Spottswood

Dr. Rettew’s column last month detailed the systems that are changing (slowly!) to better facilitate interface between mental health and primary care. There are increasingly supports available at a clinic level, and also a state level. Regardless of where your practice is in the process of integration, there are some key resources available now that can be used by child psychiatrists and pediatricians alike. This moment in time seems like a great opportunity to review a few favorites.
 

Who you gonna call?

Child Psychiatry Access Programs, sometimes called Psychiatry Access Lines, are almost everywhere!¹ If you haven’t called one yet, click on your state and call! You will have immediate access to mental health resources that are curated and available in your state, child psychiatry expertise, and a way to connect families in need with targeted treatments. A long-term side effect of CPAP utilization may include improved system coordination on behalf of kids.

What about screening?

The AAP has an excellent mental health minute on screening.² Pediatricians screen thoughtfully for psychosocial and medical concerns. Primary and secondary screenings for mental health are becoming ubiquitous in practices as a first step toward diagnosis and treatment. Primary, or initial, screening can catch concerns in your patient population. These include common tools like the Strengths and Difficulties Questionnaire (SDQ, ages 2-17), or the Pediatric Symptom Checklist (PSC-14, ages 4-17). Subscale scores help point care toward the right direction.

Once we know there is a mental health problem through screening or interview, secondary mental health screening and rating scales help find a specific diagnosis. Some basics include the PHQ-A for depression (ages 11-17), the GAD-7 for general anxiety (ages 11+), the SCARED for specific anxiety (ages 8-18), and the Vanderbilt (ages 6+) or SNAP-IV (ages 5+) parent/teacher scales for ADHD/ODD/CD/anxiety/depressive symptoms. The CY-BOCS symptom checklist (ages 6-17) is excellent to determine the extent of OCD symptoms. The asQ (ages 10+) and Columbia (C-SSRS, ages 11+) are must-use screeners to help prevent suicide. Screeners and rating scales are found on many CPAP websites, such as New York’s.³ A site full of these can seem overwhelming, but once you get comfortable with a few favorites, expanding your repertoire little by little makes providing care a lot easier!
 

Treating to target?

When you are fairly certain of the diagnosis, you can feel more confident to treat. Diagnoses can be tools; find the best fit one, and in a few years with more information, a different tool might be a better fit.

Some favorite treatment resources include the CPAP guidebook from your state (for example, Washington’s⁴ and Virginia’s⁵), and the AACAP parent medication guides.⁶ They detail evidence-based treatments including medications, and can help us professionals and high health care–literacy families. The medication tracking form found at the back of each guide is especially key. Another great book is the DSM 5 Pocket Guide for Child and Adolescent Mental Health.⁷ Some screeners can be repeated to see if treatment is working, as the AIMS model suggests “treat to target”⁸ specific symptoms until they improve.
 

How to provide help with few resources?

There is knowing what your patient needs, like a specific therapy, and then there is the challenge of connecting the patient with help. Getting a family started on a first step of treatment while they are on a waiting list can be transformative. One example is treatment for oppositional defiant disorder (ODD); parents can start with the first step, “special time,”⁹ even before a therapist is available. Or, if a family is struggling with OCD, they can start an Exposure Therapy with Response Prevention (ERP) workbook¹⁰ or look at the iocdf.org website before seeing a specialized therapist. We all know how unsatisfactory a wait-list is as a treatment plan; it is so empowering to start the family with first steps.

What about connections for us providers?

Leveraging your own relationship with patients who have mental health challenges can be powerful, and staying connected with others is vital to maintaining your own emotional well-being. Having a therapist, being active in your medical chapters, gardening, and connecting your practice to local mental health providers and schools can be rejuvenating. Improving the systems around us prevents burnout and keeps us connected.

And finally ...

So, join the movement to help our fields work better together; walk out of that exam room and listen to your worry about your patients and the systems that support them. Reach out for help, toward child psychiatry access lines, the AAP, AACAP, and other collective agents of change. Share what is making your lives and your patients’ lives easier so we can amplify these together. Let’s worry together, and make things better.

Dr. Margaret Spottswood is a child psychiatrist practicing in an integrated care clinic at the Community Health Centers of Burlington, Vt., a Federally Qualified Health Center. She is also the medical director of the Vermont Child Psychiatry Access Program and a clinical assistant professor in the department of psychiatry at the University of Vermont, Burlington.

References

1. National Network of Child Psychiatry Access Programs. Child Psychiatry Access Programs in the United States. https://www.nncpap.orgmap. 2023 Mar 14.

2. American Academy of Pediatrics. Screening Tools: Pediatric Mental Health Minute Series. https://www.aap.org/en/patient-care/mental-health-minute/screening-tools.

3. New York ProjectTEACH. Child Clinical Rating Scales. https://projectteachny.org/child-rating-scales.

4. Hilt H, Barclay R. Seattle Children’s Primary Care Principles for Child Mental Health. https://www.seattlechildrens.org/globalassets/documents/healthcare-professionals/pal/wa/wa-pal-care-guide.pdf.

5. Virginia Mental Health Access Program. VMAP Guidebook. https://vmap.org/guidebook.

6. American Academy of Child and Adolescent Psychiatry. Parents’ Medication Guides. https://www.aacap.org/AACAP/Families_and_Youth/Family_Resources/Parents_Medication_Guides.aspx.

7. Hilt RJ, Nussbaum AM. DSM-5 Pocket Guide to Child and Adolescent Mental Health. Arlington, Va.: American Psychiatric Association Publishing, 2015.

8. Advanced Integration Mental Health Solutions. Measurement-Based Treatment to Target. https://aims.uw.edu/resource-library/measurement-based-treatment-target.

9. Vermont Child Psychiatry Access Program. Caregiver Guide: Special Time With Children. https://www.chcb.org/wp-content/uploads/2023/03/Special-Time-with-Children-for-Caregivers.pdf.

10. Reuter T. Standing Up to OCD Workbook for Kids. New York: Simon and Schuster, 2019.

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

Case: “Where’s my mommy?”

A 13-year-old girl “D” appeared lifeless in her hospital bed, swallowed by tubes, gauze, and crisp white sheets. She seemed fragile next to the giant machines beeping all around her, as they churned and groaned to keep her alive. She was in the pediatric intensive care unit, a place she had only seen once or twice on TV. Her sleeping mother lay next to her in an uncomfortable-looking recliner chair, curled up in a ball. She abruptly woke up when I walked into the room, doing her best to wipe away 5 days’ worth of worry and sadness from her exhausted face. She saw “Child Psychiatrist” written on my hospital badge, desperately searching my face for answers or a sign of hope.

Her daughter – a straight-A middle school student who loved Taylor Swift and soccer – had overdosed on Tylenol after discovering that she did not make the cheerleading team. I reported that her daughter’s liver enzymes were finally trending down and that she would likely not require a liver transplant. She would survive. As tears welled up in this mother’s eyes, I heard a faint whisper from across the room. “Where’s my mommy?” D was awake and frantically searching the room for her mother, someone who could soothe her in this living nightmare. As the two embraced, I felt tears well up in my eyes as I couldn’t help but think of my own 3-year-old daughter at home. How could I protect her from the sadness and despair that this little girl was feeling? How can we collectively protect every little girl from wanting to end their life?

CDC data: Teen girls need help now

The latest biennial Centers for Disease Control and Prevention Youth Risk Behavior Survey, administered in the fall of 2021, resulted in alarming data showing that mental health has worsened for all adolescents, but especially for girls. The survey was administered to more than 17,000 students in 152 public and private schools throughout the United States, showing that “America’s teen girls are engulfed in a growing wave of sadness, violence, and trauma.”¹ In particular, rates of sadness, suicidal ideation, suicide attempts, and mental health crisis ED visits among girls are the highest reported in a decade. Nearly 60% of girls felt persistent sadness or hopelessness during the past year, double the rate of boys. More than 25% of girls made a suicide plan; this percentage increased 60% over the past 10 years. Alarmingly, ED visits for suicide attempts for girls increased more than 50% in the past 2 years alone.

Even before the COVID-19 pandemic, experts were sounding the alarm on the growing rates of anxiety and depression in U.S. youth. The pandemic-driven isolation, lack of social connection, and missing of major milestones did not help the situation and only deepened the cracks in a faulty mental health care system. Further, civil unrest and social upheaval in the United States felt – and continues to feel – chaotic and unpredictable. For teens, the current cultural climate represents their not-too-distant future as adults, causing worry and anxiety.

In addition to securing their futures through performance in school and extracurricular activities, teenagers are forming their identities. Establishing a personal identity is a difficult task for all teens, though teenage girls face uniquely difficult challenges in our current society. In particular, teenage girls are expected to conform their behaviors to fit societal expectations that may clash with their desires and self-conceptualization. This conflict is further complicated by heightened beauty standards, online hate and competition, academic pressure, and self-doubt. CDC data show that girls experience sexual harassment and cyberbullying at roughly twice the rate of their male counterparts. Girls also experience higher levels of sexual violence and bullying. Alarmingly, 14% of girls reported being forced to have sex at some point in their lives. The sad truth is that, for every 10 teenage girls you know, at least one of them, and probably more, has likely been raped.
 

A call to action for providers

As providers, what can we do about these alarming statistics? It’s easy to become overwhelmed by data on a national level. However, regardless of our current clinical practice situation, we cannot lose sight of the humanity behind these numbers. Five extra minutes of truly listening to our patients, normalizing conversations about mental health, and looking for mental health warning signs (that is, increased isolation, declining function in school, maladaptive coping skills such as self-injurious behavior or substance use) can mean the difference between life and death.

As pediatric providers, formally screening for suicide risk is critical. Specifically, the American Academy of Pediatrics recommends that all youth aged 12 years or older be screened for suicide risk.² In addition to asking families to reduce access to lethal means, it is important to utilize suicide-specific screeners to prevent suicide attempts and deaths in the pediatric community. Pediatric providers must feel prepared to counsel patients and families on suicide prevention and, if this skill set is underdeveloped, appropriate referrals and support must be provided.

At the same time, it is important to note the larger context. This national tragedy has been long-standing and further accelerated by the social isolation and stress of the pandemic. Madigan and colleagues recently showed that the lack of a social outlet resulting from COVID-19 caused an increase in screen time among all children.³ As a result, many teen girls turned to social media to recreate these social connections online.⁴ This dependence on social media for validation has contributed to increased rates of depression by intensifying unrealistic body standards, comparisons, and competition among peers.⁵ However, recent pediatric partnership programs have improved mental health access, reduced ED visits, and increased primary care physician’s comfort with managing mental health concerns.⁶ These programs are called Child Psychiatry Access Programs (CPAPs) and utilize a collaborative care model through which primary care clinicians consult with child and adolescent psychiatrists. CPAPs, while not the entire solution, offer a major step in the right direction toward tackling this mental health crisis in a sustainable, collaborative, and effective way.

As students return to in-person learning, connectedness at school is a powerful protective factor against depression and anxiety. We must infuse resources and support into our schools and teachers, as they stand on the front lines for our children. Specifically, bolstering schools with school counselors and appropriate mental health support staff will help rescue teachers from burnout while also explicitly identifying mental health care as a priority. Finally, modeling positive behavior for families and identifying safe adults at school can help at-risk youth feel more connected. To achieve meaningful improvement in children’s mental health, it is crucial to collaboratively remodel broken systems to ensure that all children are supported early, effectively, and equitably.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences, program director of the child and adolescent psychiatry fellowship, and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior in Los Angeles.
 

References

1. Centers for Disease Control and Prevention. YRBSS Data Summary & Trends. 2023 Feb 13. https://www.cdc.gov/healthyyouth/data/yrbs/yrbs_data_summary_and_trends.htm

2. American Academy of Pediatrics. Screening for Suicide Risk in Clinical Practice. 2023 Feb 22. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/strategies-for-clinical-settings-for-youth-suicide-prevention/screening-for-suicide-risk-in-clinical-practice/

3. Madigan S et al. JAMA Pediatr. 2022;176(12):1188-98. doi: 10.1001/JAMAPEDIATRICS.2022.4116

4. Pew Research Center. Teens, Social Media and Technology 2022. 2022 Aug 10. https://www.pewresearch.org/internet/2022/08/10/teens-social-media-and-technology-2022/

5. Hunt MG et al. J Social Clin Psychology. 2018;37(10):751-68. doi: 10.1521/JSCP.2018.37.10.751

6. Godoy L et al. J Pediatr Health Care. 2022 Dec 16. doi: 10.1016/j.pedhc.2022.11.009.

Case: “Where’s my mommy?”

A 13-year-old girl “D” appeared lifeless in her hospital bed, swallowed by tubes, gauze, and crisp white sheets. She seemed fragile next to the giant machines beeping all around her, as they churned and groaned to keep her alive. She was in the pediatric intensive care unit, a place she had only seen once or twice on TV. Her sleeping mother lay next to her in an uncomfortable-looking recliner chair, curled up in a ball. She abruptly woke up when I walked into the room, doing her best to wipe away 5 days’ worth of worry and sadness from her exhausted face. She saw “Child Psychiatrist” written on my hospital badge, desperately searching my face for answers or a sign of hope.

Her daughter – a straight-A middle school student who loved Taylor Swift and soccer – had overdosed on Tylenol after discovering that she did not make the cheerleading team. I reported that her daughter’s liver enzymes were finally trending down and that she would likely not require a liver transplant. She would survive. As tears welled up in this mother’s eyes, I heard a faint whisper from across the room. “Where’s my mommy?” D was awake and frantically searching the room for her mother, someone who could soothe her in this living nightmare. As the two embraced, I felt tears well up in my eyes as I couldn’t help but think of my own 3-year-old daughter at home. How could I protect her from the sadness and despair that this little girl was feeling? How can we collectively protect every little girl from wanting to end their life?

CDC data: Teen girls need help now

The latest biennial Centers for Disease Control and Prevention Youth Risk Behavior Survey, administered in the fall of 2021, resulted in alarming data showing that mental health has worsened for all adolescents, but especially for girls. The survey was administered to more than 17,000 students in 152 public and private schools throughout the United States, showing that “America’s teen girls are engulfed in a growing wave of sadness, violence, and trauma.”¹ In particular, rates of sadness, suicidal ideation, suicide attempts, and mental health crisis ED visits among girls are the highest reported in a decade. Nearly 60% of girls felt persistent sadness or hopelessness during the past year, double the rate of boys. More than 25% of girls made a suicide plan; this percentage increased 60% over the past 10 years. Alarmingly, ED visits for suicide attempts for girls increased more than 50% in the past 2 years alone.

Even before the COVID-19 pandemic, experts were sounding the alarm on the growing rates of anxiety and depression in U.S. youth. The pandemic-driven isolation, lack of social connection, and missing of major milestones did not help the situation and only deepened the cracks in a faulty mental health care system. Further, civil unrest and social upheaval in the United States felt – and continues to feel – chaotic and unpredictable. For teens, the current cultural climate represents their not-too-distant future as adults, causing worry and anxiety.

In addition to securing their futures through performance in school and extracurricular activities, teenagers are forming their identities. Establishing a personal identity is a difficult task for all teens, though teenage girls face uniquely difficult challenges in our current society. In particular, teenage girls are expected to conform their behaviors to fit societal expectations that may clash with their desires and self-conceptualization. This conflict is further complicated by heightened beauty standards, online hate and competition, academic pressure, and self-doubt. CDC data show that girls experience sexual harassment and cyberbullying at roughly twice the rate of their male counterparts. Girls also experience higher levels of sexual violence and bullying. Alarmingly, 14% of girls reported being forced to have sex at some point in their lives. The sad truth is that, for every 10 teenage girls you know, at least one of them, and probably more, has likely been raped.
 

A call to action for providers

As providers, what can we do about these alarming statistics? It’s easy to become overwhelmed by data on a national level. However, regardless of our current clinical practice situation, we cannot lose sight of the humanity behind these numbers. Five extra minutes of truly listening to our patients, normalizing conversations about mental health, and looking for mental health warning signs (that is, increased isolation, declining function in school, maladaptive coping skills such as self-injurious behavior or substance use) can mean the difference between life and death.

As pediatric providers, formally screening for suicide risk is critical. Specifically, the American Academy of Pediatrics recommends that all youth aged 12 years or older be screened for suicide risk.² In addition to asking families to reduce access to lethal means, it is important to utilize suicide-specific screeners to prevent suicide attempts and deaths in the pediatric community. Pediatric providers must feel prepared to counsel patients and families on suicide prevention and, if this skill set is underdeveloped, appropriate referrals and support must be provided.

At the same time, it is important to note the larger context. This national tragedy has been long-standing and further accelerated by the social isolation and stress of the pandemic. Madigan and colleagues recently showed that the lack of a social outlet resulting from COVID-19 caused an increase in screen time among all children.³ As a result, many teen girls turned to social media to recreate these social connections online.⁴ This dependence on social media for validation has contributed to increased rates of depression by intensifying unrealistic body standards, comparisons, and competition among peers.⁵ However, recent pediatric partnership programs have improved mental health access, reduced ED visits, and increased primary care physician’s comfort with managing mental health concerns.⁶ These programs are called Child Psychiatry Access Programs (CPAPs) and utilize a collaborative care model through which primary care clinicians consult with child and adolescent psychiatrists. CPAPs, while not the entire solution, offer a major step in the right direction toward tackling this mental health crisis in a sustainable, collaborative, and effective way.

As students return to in-person learning, connectedness at school is a powerful protective factor against depression and anxiety. We must infuse resources and support into our schools and teachers, as they stand on the front lines for our children. Specifically, bolstering schools with school counselors and appropriate mental health support staff will help rescue teachers from burnout while also explicitly identifying mental health care as a priority. Finally, modeling positive behavior for families and identifying safe adults at school can help at-risk youth feel more connected. To achieve meaningful improvement in children’s mental health, it is crucial to collaboratively remodel broken systems to ensure that all children are supported early, effectively, and equitably.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences, program director of the child and adolescent psychiatry fellowship, and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior in Los Angeles.
 

References

1. Centers for Disease Control and Prevention. YRBSS Data Summary & Trends. 2023 Feb 13. https://www.cdc.gov/healthyyouth/data/yrbs/yrbs_data_summary_and_trends.htm

2. American Academy of Pediatrics. Screening for Suicide Risk in Clinical Practice. 2023 Feb 22. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/strategies-for-clinical-settings-for-youth-suicide-prevention/screening-for-suicide-risk-in-clinical-practice/

3. Madigan S et al. JAMA Pediatr. 2022;176(12):1188-98. doi: 10.1001/JAMAPEDIATRICS.2022.4116

4. Pew Research Center. Teens, Social Media and Technology 2022. 2022 Aug 10. https://www.pewresearch.org/internet/2022/08/10/teens-social-media-and-technology-2022/

5. Hunt MG et al. J Social Clin Psychology. 2018;37(10):751-68. doi: 10.1521/JSCP.2018.37.10.751

6. Godoy L et al. J Pediatr Health Care. 2022 Dec 16. doi: 10.1016/j.pedhc.2022.11.009.

Case: “Where’s my mommy?”

A 13-year-old girl “D” appeared lifeless in her hospital bed, swallowed by tubes, gauze, and crisp white sheets. She seemed fragile next to the giant machines beeping all around her, as they churned and groaned to keep her alive. She was in the pediatric intensive care unit, a place she had only seen once or twice on TV. Her sleeping mother lay next to her in an uncomfortable-looking recliner chair, curled up in a ball. She abruptly woke up when I walked into the room, doing her best to wipe away 5 days’ worth of worry and sadness from her exhausted face. She saw “Child Psychiatrist” written on my hospital badge, desperately searching my face for answers or a sign of hope.

Her daughter – a straight-A middle school student who loved Taylor Swift and soccer – had overdosed on Tylenol after discovering that she did not make the cheerleading team. I reported that her daughter’s liver enzymes were finally trending down and that she would likely not require a liver transplant. She would survive. As tears welled up in this mother’s eyes, I heard a faint whisper from across the room. “Where’s my mommy?” D was awake and frantically searching the room for her mother, someone who could soothe her in this living nightmare. As the two embraced, I felt tears well up in my eyes as I couldn’t help but think of my own 3-year-old daughter at home. How could I protect her from the sadness and despair that this little girl was feeling? How can we collectively protect every little girl from wanting to end their life?

CDC data: Teen girls need help now

The latest biennial Centers for Disease Control and Prevention Youth Risk Behavior Survey, administered in the fall of 2021, resulted in alarming data showing that mental health has worsened for all adolescents, but especially for girls. The survey was administered to more than 17,000 students in 152 public and private schools throughout the United States, showing that “America’s teen girls are engulfed in a growing wave of sadness, violence, and trauma.”¹ In particular, rates of sadness, suicidal ideation, suicide attempts, and mental health crisis ED visits among girls are the highest reported in a decade. Nearly 60% of girls felt persistent sadness or hopelessness during the past year, double the rate of boys. More than 25% of girls made a suicide plan; this percentage increased 60% over the past 10 years. Alarmingly, ED visits for suicide attempts for girls increased more than 50% in the past 2 years alone.

Even before the COVID-19 pandemic, experts were sounding the alarm on the growing rates of anxiety and depression in U.S. youth. The pandemic-driven isolation, lack of social connection, and missing of major milestones did not help the situation and only deepened the cracks in a faulty mental health care system. Further, civil unrest and social upheaval in the United States felt – and continues to feel – chaotic and unpredictable. For teens, the current cultural climate represents their not-too-distant future as adults, causing worry and anxiety.

In addition to securing their futures through performance in school and extracurricular activities, teenagers are forming their identities. Establishing a personal identity is a difficult task for all teens, though teenage girls face uniquely difficult challenges in our current society. In particular, teenage girls are expected to conform their behaviors to fit societal expectations that may clash with their desires and self-conceptualization. This conflict is further complicated by heightened beauty standards, online hate and competition, academic pressure, and self-doubt. CDC data show that girls experience sexual harassment and cyberbullying at roughly twice the rate of their male counterparts. Girls also experience higher levels of sexual violence and bullying. Alarmingly, 14% of girls reported being forced to have sex at some point in their lives. The sad truth is that, for every 10 teenage girls you know, at least one of them, and probably more, has likely been raped.
 

A call to action for providers

As providers, what can we do about these alarming statistics? It’s easy to become overwhelmed by data on a national level. However, regardless of our current clinical practice situation, we cannot lose sight of the humanity behind these numbers. Five extra minutes of truly listening to our patients, normalizing conversations about mental health, and looking for mental health warning signs (that is, increased isolation, declining function in school, maladaptive coping skills such as self-injurious behavior or substance use) can mean the difference between life and death.

As pediatric providers, formally screening for suicide risk is critical. Specifically, the American Academy of Pediatrics recommends that all youth aged 12 years or older be screened for suicide risk.² In addition to asking families to reduce access to lethal means, it is important to utilize suicide-specific screeners to prevent suicide attempts and deaths in the pediatric community. Pediatric providers must feel prepared to counsel patients and families on suicide prevention and, if this skill set is underdeveloped, appropriate referrals and support must be provided.

At the same time, it is important to note the larger context. This national tragedy has been long-standing and further accelerated by the social isolation and stress of the pandemic. Madigan and colleagues recently showed that the lack of a social outlet resulting from COVID-19 caused an increase in screen time among all children.³ As a result, many teen girls turned to social media to recreate these social connections online.⁴ This dependence on social media for validation has contributed to increased rates of depression by intensifying unrealistic body standards, comparisons, and competition among peers.⁵ However, recent pediatric partnership programs have improved mental health access, reduced ED visits, and increased primary care physician’s comfort with managing mental health concerns.⁶ These programs are called Child Psychiatry Access Programs (CPAPs) and utilize a collaborative care model through which primary care clinicians consult with child and adolescent psychiatrists. CPAPs, while not the entire solution, offer a major step in the right direction toward tackling this mental health crisis in a sustainable, collaborative, and effective way.

As students return to in-person learning, connectedness at school is a powerful protective factor against depression and anxiety. We must infuse resources and support into our schools and teachers, as they stand on the front lines for our children. Specifically, bolstering schools with school counselors and appropriate mental health support staff will help rescue teachers from burnout while also explicitly identifying mental health care as a priority. Finally, modeling positive behavior for families and identifying safe adults at school can help at-risk youth feel more connected. To achieve meaningful improvement in children’s mental health, it is crucial to collaboratively remodel broken systems to ensure that all children are supported early, effectively, and equitably.

Dr. Richards is assistant clinical professor in the department of psychiatry and biobehavioral sciences, program director of the child and adolescent psychiatry fellowship, and associate medical director of the perinatal program at the UCLA Semel Institute for Neuroscience and Human Behavior in Los Angeles.
 

References

1. Centers for Disease Control and Prevention. YRBSS Data Summary & Trends. 2023 Feb 13. https://www.cdc.gov/healthyyouth/data/yrbs/yrbs_data_summary_and_trends.htm

2. American Academy of Pediatrics. Screening for Suicide Risk in Clinical Practice. 2023 Feb 22. https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/strategies-for-clinical-settings-for-youth-suicide-prevention/screening-for-suicide-risk-in-clinical-practice/

3. Madigan S et al. JAMA Pediatr. 2022;176(12):1188-98. doi: 10.1001/JAMAPEDIATRICS.2022.4116

4. Pew Research Center. Teens, Social Media and Technology 2022. 2022 Aug 10. https://www.pewresearch.org/internet/2022/08/10/teens-social-media-and-technology-2022/

5. Hunt MG et al. J Social Clin Psychology. 2018;37(10):751-68. doi: 10.1521/JSCP.2018.37.10.751

6. Godoy L et al. J Pediatr Health Care. 2022 Dec 16. doi: 10.1016/j.pedhc.2022.11.009.