Tanuja Gandhi, MD (Host): Welcome back to Mindcast, a podcast from the experts at Bradley Hospital, the nation's first pediatric psychiatric hospital. I'm Dr. Tanuja Gandhi, your co-host.

Greg Fritz, MD (Host): I'm Dr. Greg Fritz, your other co-host. Today we're diving into a crucial topic and that's how to get mental health services for your child when you think that he or she needs it.

This is a big one. It really is. There's so many challenges parents face when trying to navigate our unfortunately, too complicated system.

Tanuja Gandhi, MD (Host): I totally agree with that. From the mental health crisis among children and youth today, to the shortage of mental health clinicians, the complexities of insurance coverage, and just getting access to care, it can be overwhelming and very frustrating at times, but today we're joined by Don Laliberte, the Director of the ACCESS program here at Bradley, who can share some insights and helpful tips on the process. Welcome Don.

Don Laliberte, LICSW: Thank you for having me and I'm glad to be here. I hope that after we're done, that things will seem a little bit less complicated because even though sometimes it's a challenge, there are a lot of resources available out there for people who are concerned about their children.

Greg Fritz, MD (Host): Well, that's good to know and a hopeful thought. Let's start by addressing the mental health crisis among youth that we're all really aware of today. And it's such a dramatic change since the pandemic in terms of kids needs that the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics have labeled this a national crisis in child mental health.

 That's the first time that's ever happened and it really draws attention to it. And so, just reflects that so many kids are struggling these days.

Don Laliberte, LICSW: That is true. The numbers are going up and they have been going up. The thing to know though is the numbers actually started to go up before the pandemic. And the pandemic made it much worse. And the thing that we have seen is not just more numbers of children affected by the crisis by mental health

issues,

but the severity of the issues that they're dealing with. And, we see people coming to the emergency room much more often. We see high acuity situations, whereas at one time we might've seen people in the emergency room who were mildly depressed and didn't know where to go. Whereas now we see people with a lot more imminent risk and a lot more really serious situations.

Tanuja Gandhi, MD (Host): One major hurdle is the shortage of mental health clinicians. Even after a child has been assessed in the emergency room or discharged from the hospital, there just aren't enough professionals to meet the demand and provide continuity of care in the community.

And this means more children presenting to the emergency room or crisis rooms for an evaluation, fewer people to take care of them, longer wait times, and you know, the circle goes on again with limited access to care.

Don Laliberte, LICSW: Exactly, and people who are looking for services for their child who need a clinician, they may find that the person they reach out to has a waiting list of six or eight months. They may not take that person's insurance. There are all these other things that people have to navigate. So once they find a provider, they may then have to get preauthorizations and approvals and all of those things. And it can be very challenging. We hear it all the time from parents where they've tried and tried and just can't get a person to see their child.

Greg Fritz, MD (Host): So where can parents go for help?

Don Laliberte, LICSW: Well, I would say that a couple of things people can start with this. The first place if people are not involved in any sort of care anywhere is I would suggest people start with their primary care provider. Their primary care doctor would generally know their child. They'll have some sense of who they are and they will be able to rule out any medical issues that might be causing the mental health issues.

So, they may be able to help with those sorts of things. They also may have referral information and resources and providers that they are aware of that they can refer the child to.

Tanuja Gandhi, MD (Host): I think the other thing that can be done is that, you know, if you go to your primary care provider, a pediatrician, even they can consider if it's a situation or a condition that they can manage, starting treatment themselves. And I'm aware of a very spectacular service, that's the PDPRN, where pediatricians can reach out for support with complicated conditions.

So, Don, can you also talk a little bit about schools, which are the other first point of contact for children?

Don Laliberte, LICSW: Schools can be really helpful to people and it can be a challenge because schools are overwhelmed and even in school systems, there aren't enough social workers or psychologists to meet everyone's needs.

So that can be a challenge at times, but there are a lot of schools that have mental health professionals integrated into their system. So the community mental health center may have somebody who actually spends a couple of days a week at a particular school to be available to children that are having mental health crises.

So a good place for parents to start is to talk to the people at the school. Start with the teacher, start with the counseling staff, the support staff to see if they have any resources available there.

Tanuja Gandhi, MD (Host): And what about other supports like family and friends?

Don Laliberte, LICSW: People often forget about natural supports like families and friends. Sometimes the support networks that they have, people may already know someone who is available.

They may know a provider. They may have ACCESS services for their own child. Another option is if people are involved in a faith community that clergy can provide support. They can also, they can provide pastoral counseling and they also may have access to other resources for them. So we don't want to forget that there are other natural resources in the community.

Greg Fritz, MD (Host): So, the other thing is there's a proliferation of resource and referral lines. And they can, I think, from my understanding, although I don't have personal experience with it, these can be really useful to parents. For instance, the 211 line is a national service that can help connect you to local resources, I'm told. Have you had experience with these from the talk to parents who have used these lines?

Don Laliberte, LICSW: Absolutely I have. I've had experience with people who have accessed 211, 211 in Rhode Island is operated through the United Way and they get numerous calls per year. They can help not just with mental health referrals, they can help with all sorts of other issues; social determinants of health, income supports, medical referrals, all sorts of things. So 211 is a very helpful resource to a lot of people that need services in general. But if someone calls 211 looking for mental health care, they can get some referrals there. In Rhode Island, we're very lucky that we also have KidsLink, which is run right here through Bradley Hospital.

And KidsLink is our 24 hour pediatric behavioral health triage and referral service that will provide someone to answer the phone and give support and information to people who are concerned about a child. We get calls from parents, mental health providers, medical providers, schools, a lot of different people calling us.

We average about 8,000 calls a year. So we are available for people in Rhode Island who are just looking to get some services for their child, whether it's outpatient mental health services, or if it's a crisis and we would refer them to a higher level of care.

Greg Fritz, MD (Host): So that's been going on for quite a while, right?

Don Laliberte, LICSW: KidsLink has been going on

Greg Fritz, MD (Host): Pre pandemic.

Don Laliberte, LICSW: 2015? Uh huh. It was before I started working here, but, it's been quite a while, yes.

Greg Fritz, MD (Host): Certainly has made an impact on our state, and I it's been a model for several others that are underway.

Don Laliberte, LICSW: Absolutely.

Tanuja Gandhi, MD (Host): So this gets me thinking, is KidsLink like a emergency line and, if your child is in like a crisis where there's risk of safety, do you call KidsLink instead of calling 911?

Don Laliberte, LICSW: No, if your child is in imminent danger, call 911. Safety comes first and that's the most important thing. We do get calls from people who don't know whether to call 911 or not, and we process that with them. And if we think it's an emergency situation, we will tell them, get 911 right now. We get a lot more calls from people who are frustrated with the system, been trying to get outpatient care or their child is in outpatient care and isn't getting any better.

Do they need a higher level of care or those kinds of things? So we're not a hotline in that sense for people to call when they're in crisis. If people call us in crisis, we absolutely try to help them, but we don't, that isn't our primary purpose.

Tanuja Gandhi, MD (Host): Very helpful. And, from my experience working on the inpatient unit, I've learned that sometimes to find community resources, depending on your insurance, parents and families can look up the website of the insurance company, which has a list of clinicians that they can reach out to and if there is a particular clinician that's within travel distance or someone they would prefer to go to, they could reach out to them directly, which is another way of finding a community resource.

Don Laliberte, LICSW: That's right. And if they want to, if they don't want to use the web, they can most of the time look at the back of their insurance card and it should be a toll free number. It would most often say for behavioral health emergencies or information. If they call, they should be able to speak to someone who can connect them to a provider that's in network with that insurance company and hopefully within travel distance.

Tanuja Gandhi, MD (Host): So let's talk about what to do in an emergency. I know you've highlighted some of the points, but say if a child is in immediate danger, be it a safety for themselves or their family, there are several options. That's my understanding. Could you help us understand what parents should do?

Like walk us through the process. If someone's facing it for the first time, how do they think through a crisis situation?

Don Laliberte, LICSW: That's a really good question. I think the way I would suggest to the parents is that they start by talking to the child and be willing to talk to the child about what's going on. So if you have a child who is depressed and is making vague statements about I wish I were dead. I wish I could go to sleep and not wake up, but not saying anything else; that might be a good call to KidsLink, cause we can help triage that through. If you have a child who is making direct threats to harm themselves or direct threats to harm someone else, or they're engaging in behavior in the home that is destructive and dangerous; if their behavior is so dysregulated that they're, I don't know, throwing furniture, throwing objects, doing things like that, those kinds of cases, the people need to get their child to the emergency room. If it's an imminent risk, we would recommend that they call 911 and get an ambulance to take them. We don't often recommend that people transport their own child who's in immediate danger because it can just be very challenging and very dangerous that way.

Greg Fritz, MD (Host): Jumping out of the car or something.

Don Laliberte, LICSW: Jumping out of the car, unbuckling their seatbelt. I've had stories where parents have told me that a child tried to grab the steering wheel while they were driving on the road. Nobody wants to be in that kind of situation. There are professionals who can help with that.

The other thing, if it's not that situation, if it's not the level where a person needs to go to an emergency room right now, like I said, we can call KidsLink, we can help determine levels of care. Most community mental health centers will have some sort of emergency line.

And one of the newer services that's available now are mobile crisis units that are being started by several agencies in Rhode Island and they will actually go out and do an evaluation in the home. We like to talk about the difference between an urgent situation and an emergent situation.

In an emergency, then get the kid to the emergency room right away as quickly as possible. If it's urgent but they're not doing anything that's immediately dangerous, then that's where calling a place like KidsLink. Calling mobile crisis team, someone like that can be helpful and they might be able to divert someone from having to go to the hospital.

Greg Fritz, MD (Host): This workforce shortage has been recognized for a while and in addition to trying to develop the responses that we've talked about here. The professional organizations, are also trying to do things to increase the number of people that are going into the mental health professions and nationally this is a huge shortage that predates the pandemic and it's not something that is going to happen and be cured in the next year and a half or something.

It's a long undertaking, but the estimate is that there's less than a quarter of the total number mental health professionals for children, now available compared to what's needed. It's a huge shortage and over half the kids with mental health diagnoses in epidemiologic studies aren't getting any treatment at all.

So parents are right to feel that they're paddling upstream and we hope we can do as much as we can to help that. But it's a basic issue. And the other thing that I think is interesting, and if people want to look at it, the American Academy of Child and Adolescent Psychiatry has an interesting county by county map of child psychiatrists in the country.

And just, depicts on a map the same things we were talking about. There just is a terrible dearth. So we're struggling and, I think these points that you're making are very useful and we have to be aware that despite the problem, there are solutions so it's been great to have you, Don.

Don Laliberte, LICSW: The other thing to think about with that is that despite the problem, there are solutions, and it requires some persistence, and I would encourage families or anyone that's, any caregiver that's concerned about a child, not to give up just because of the challenge of getting someone to see their child, and to reach out to places like KidsLink, where we keep track of about 400 different providers in the state, and we call them at least once a month and find out are they taking new patients?

Are they doing virtual appointments? Are they doing in person appointments? What insurances do they take? So our goal is that when people are struggling with the system, that if they call someone like us, they get a person that it can actually be available to them. So, reach out and get someone to help you. If it's not in Rhode Island and it's not KidsLink, there are similar services in other areas.

Tanuja Gandhi, MD (Host): I heard that there's an effort to come up with programs that cover treatment virtually across state lines. There's a similar program that's coming out through Bradley, too.

Don Laliberte, LICSW: Oh, yes. I think you might be talking about the REACH program.

Tanuja Gandhi, MD (Host): The REACH program, yes.

Don Laliberte, LICSW: Yes, REACH doesn't to me, so I won't be able to tell you everything about it. But the REACH program is a very innovative full day and half day partial hospital program that provides services virtually to people who need partial hospital level of care.

So what they do is they see people, people log in through Zoom, and they do individual care, individual appointments, group therapy, they have psychiatry available, they have people that work and help to reintegrate the child back into school or whatever resources they have. It's interesting because a lot of families, when we speak to them, if they happen to call KidsLink, there's some anxiety about doing virtual care.

But, what I've heard from the people who work in REACH is that the outcomes are the same as others. And they're, especially with adolescents, so much of their world is digital now, and they text, they FaceTime, they do all of that. So what seems strange to some people that I'm talking to people on a computer isn't strange necessarily to young people. So it has been shown to be a very effective program.

Tanuja Gandhi, MD (Host): That is so good to hear. And the only other thing I'd like to add is the stigma around seeking help for your child. Unless you've seen a child in crisis or know a child in crisis, for a lot of people, it seems kind of shocking that a child can be depressed or have suicidal thoughts or basically have mental health issues.

But coming from this world in our clinical practice, we've seen kids as young as four and five deal with emotional and behavioral problems. So it's not that unusual. So I think it's important for families to think about getting help early if there is an ongoing situation or crisis in their home and not wait till it becomes much more difficult to handle.

Don Laliberte, LICSW: Right. For most other types of illnesses, if we get care early, we reduce the chance of a crisis happening down the road. So we're really happy when we get a call from someone who's noticing symptoms of depression in their child and wanting to do something now rather than waiting until the child becomes severely depressed and ends up having to go to the emergency room or get admitted inpatient.

So yes, the stigma does keep people away and anything we can do, any knowledge we can give people to reduce stigma about asking for help is definitely a good thing.

Tanuja Gandhi, MD (Host): Well, Don, this has been an enlightening conversation. And as frustrating and hopeless as the situation may seem, I think there is hope at the end of the road and it's important to keep kind of tugging along.

And there are many avenues for getting help for your child's mental health. So thank you for outlining these options and thank you for joining us today on MindCast.

Don Laliberte, LICSW: Thank you for having me.

Greg Fritz, MD (Host): I'll just add my thanks and it's been really illuminating discussion, I think. It's one that will undoubtedly help a lot of people and to our listeners, if you found today's episode interesting, check out our other podcasts at www.bradleyhospital.org/podcast. Don't forget to share it with your friends as well. So long for now.