Reimagining our Approach to the Mental Health Crisis | E. 85

The Healthcare Leadership Experience

WARNING: This episode contains discussions on sensitive mental health topics that include depression, anxiety, and suicide among youth.

Children aged 2-5 have the same rate of impairing mental health disorders as older children and adults. Dr Helen Eggar explains the work of Little Otter in addressing this growing crisis with Jim Cagliostro.

Episode Introduction

Helen explains Little Otter’s approach to mental healthcare for children, why mental health treatment hasn’t improved in ten years, and why it’s hard being a parent in America. She also describes how tantrums can be a ‘’mental health fever’’, emphasizes the need for a family focus in mental healthcare, and explains how telehealth provides access to care when 71% of counties don’t have a child psychiatrist.

Show Topics

• Mental health has deteriorated since the pandemic

• 50% of mental health disorders start before the age of 14

• Acknowledge the distressing impact of the mental health crisis

• A family focus improves mental health outcomes

• Tantrums aren’t just behavioral issues

• The vital role of telemedicine in childhood mental health

• High quality work always wins out

10:25 Mental health has deteriorated since the pandemic

Helen explained how a mental health crisis impacts the whole family.

‘’What I say about the child mental health crisis is that we were in a child mental health crisis before the pandemic, but it was made much worse by the pandemic and the stress of the pandemic. We've seen significant elevation in particularly anxiety, but also depression in kids. But this report, this white paper that I referenced that we produced was based on over 11,000 families coming to seek care at Little Otter. And when families come, they complete what we call the child and family mental health checkup, which I created. And the idea is we do checkups for height and weight and other variables, but we don't have a way to check up on our child's mental health or our family's mental health, so when families come in, they complete this survey and they immediately get a report back. And the assessment looks at child mental health with separate developmentally appropriate sections for infants, toddlers, preschoolers, school age, and middle schoolers. Then we assess parent mental health, then we assess what we call family mental health, which is stress and the relationship between the parent and partner and the co-parenting relationship. That's what we see all together. We think at Little Otter that we don't just have a child mental health crisis, we have a parent mental health crisis. In our data, over half of the parents met clinical criteria for anxiety disorder and 1/3rd met criteria for depression.

13:27 50% of mental health disorders start before the age of 14

Helen said children are affected by their environment and we cannot silo family members in treatment.

‘’Because children are impacted by their environment, by their relationships. Another example, of course, is with younger children whose parents are depressed. We know so much about postpartum depression and the impact it has on the mom. And it has a huge impact on the child's mental health. And it really impacts the quality of the parent-child relationship. Those are just two examples where we think to address this crisis where we have to innovate is not to silo the members of the family, carve them off and send them to different people, but there has to be an approach that's thinking at the family level. And I truly think that is our first big innovation at Little Otter. And the second one is to say young children are suffering at the same rates as teens. Teens, it's super important, absolutely critically important to meet the mental health needs of children. But again, if we're going to make a dent in this crisis, we have to start as early as possible. 50% of adult mental health disorders start before the age of 14, but we put most of our effort and our dollars into older children and into adults, and we're not focusing on where we can make a difference with early intervention and prevention. I'm so passionate about that, both where the industry should be focusing, but also educating parents so that they know the signs so they can advocate for what their children need and what they need.’’

15:30 Acknowledging the distressing impact of the mental health crisis

Helen said a cohesive, connected and relationship-based approach is essential in mental health care.

‘’I think one thing is that older children show up in emergency rooms with suicidal ideation at higher rates. And those are very expensive interventions, so I think that's one thing. Although the average age in our families, our kids we take care of for suicidal ideation is 10 years old. And we need to know that the second leading cause of death for children 10 to 14 is suicide. Again, it's not something that only happens to teenagers. I also think that it's somewhat more straightforward to provide mental health care to teenagers. And so at Little Otter, it's not just that we see young children, we hire therapists who are experts in early childhood mental health. It's its own area of specialization. And I think that many of the principles of our family mental health approach are embedded in the infant early childhood mental health field because you're never thinking about a three-year-old separate from the parents, you're with the child and with the parents. And so I personally think that approach should be applied across the lifespan. If you have a spouse who's depressed, it's impacting you in a huge way. And if you could be a part of that treatment to help understand and support your partner, I think treatments would be more effective. We're really trying to bring that more cohesive and connected and relationship-based approach to all of mental health.’’

20:24 A family focus improves mental health outcomes

Helen said improving the mental health of children has a major impact of parental mental health too.

‘’It does. And I can tell you a very cool thing, which is in our outcome data, taking a cohort of over 200 kids who did treatment, 71% after 12 weeks went from the clinical to the nonclinical range. They had great impact. But we saw these were parents who we were not providing direct care for, we were just working with them in our Little Otter approach, that of the parents who had clinically significant anxiety at the start of their kids' treatment, 67% were no longer in the clinical range. And for parents who had clinically significant depression at the start of treatment, 71% were no longer in the clinical range. Even just providing mental health care for children with this family focus, with this engagement with the parents with the acknowledgement of the impact on the whole family, we had a major impact on parent mental health, so we got us two for the price of one. And because we very rigorously have a measurement-based approach and track outcomes using the checkup but also other measures, we're able to demonstrate that our care, even when it's just focusing on the child, impacts and improves the mental health of parents and the mental health of the whole family.’’

25:46 Tantrums aren’t just behavioral issues

Helen explained that daily aggressive tantrums can indicate signs of a deeper problem.

‘’But I'll give you a good example from my work that I think brings it home, because it can seem abstract. Think about temper tantrums. Kids two to five have temper tantrums. In fact, 75% of two and three year olds will have had at least one tantrum last week. And it goes down a bit at four and five. And the thing about that is that is developmentally appropriate because young children are learning the capacity to manage their emotions, their big feelings, to manage behaviors when they have big feelings. And they're not that good at it, and sometimes they just melt down. However, in my research I found that children who have tantrums nearly every day and who hit, bite, kick, or break something during a tantrum, those children are eight times more likely than children who don't do that to having an impairing mental health disorder. But here's the critical thing. People think about tantrums as a behavior problem. It's as much connected to emotions. Children who have these aggressive frequent tantrums are at much higher rates of having an anxiety disorder, of having depression as well as ADHD or a behavior problem. That's why I call daily aggressive tantrums a mental health fever. It's a generalized sign that something might not be right. It doesn't tell you what it is. You have to go and have an evaluation and look more deeply. But to me, that's a useful knowledge that we can share with parents, right?...To say, "Here it is. It's developmentally typical. But actually, this is not developmentally typical, and let's look a little bit more deeply at it."

32:31 The vital role of telemedicine in childhood mental health

Helen said telehealth is on the only way to provide wider access to mental healthcare for children.

‘’I think it's a big question, can you do telemedicine in early childhood mental health? And the answer is yes. Again, science has shown that we can do that, and we're obviously doing it at Little Otter. And that is so important. We are experts in delivering telehealth to young children. You don't just plop a kid in front of a computer and expect them to talk like we're talking. You put the computer on the floor, we use the whiteboards, we have toys. We're very skilled at making it an engaging experience. But I think it's critical to understand that it is the only way we are going to address the access problem. United States, 71% of the counties in the United States do not have one child psychiatrist. There are states in the upper Midwest who have zero child psychiatrists. Yes, we have to encourage more people to go in the field, et cetera. But that is not going to be the solution. We have to be able to bring our skills to families where they are, meaning in their home. And this is critically important when you think about the need for specialization. Perhaps you're in an area that has some child mental health services but don't have specialized early childhood services. But at Little Otter, because we're 100% virtual, we can bring that expertise in. It could be early childhood mental health, but it also could be expertise in evidence-based treatment for obsessive compulsive disorder. It's not just the early childhood. The mental health care that works is evidence-based care, not just random care. And parents, I think, need to seek that high quality care.’’

38:12 High quality work always wins out

Helen said having a vision and being clear on your values and principles helps to succeed in the long-term.

‘’…my experience has been, in the end, doing high quality work wins out. I'd say that was true in terms of the beginning of my scientific career when people doubted things. But if you do good science and you have the data to show it, you will be able to convince people. And so I think having just a very clear focus on what your values are and what are the key principles that you are focusing on I think really helps build for the longterm. And I think that's the other thing. I think when we create new things, it takes a long time. And so I think it's very important not just as a leader, but for inspiring the people who work with us to have five-year plans, to think through, okay, I want to be here. And how am I going to get there? And then to support people as they go through that. I think being able to have a vision for something that doesn't exist and then be able to translate that and share that with others is one of the most amazing experiences that I've had the privilege of seeing that when you do that collaboratively... All of science, all of clinical work, this is collaborative work; doesn't just come down to one person. But if you can create those collaborative teams with vision, you can make a huge difference. And I had that in my academic career, and now I'm having the privilege of having that experience in the digital health realm.’’

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You’ll also hear:

A passion for mental health in children from birth to 6 years: Helen explains the motivation to launch Little Otter: ‘’…the earlier that we intervene, the better the outcome is for the kids.’’

No change in a decade - the urgent need to address the mental health crisis: ‘’We have a white paper that we just produced called Breaking the Silence: Meeting the Mental Health Needs of Young Children that I wrote. And in it, I look at the rates from when I started my career in the early, mid-2000s to now, 50% of children who need mental health services, only 50% get mental health services. That number was the same in 2013 as it is in 2023.’’

Mental health’s elephant in the room: ‘’The elephant in the room is something that's the crisis of mental health as a whole, which is really how mental health is funded and the lack of parity of coverage for mental health care compared to coverage for other medical disorders.’’

Why it’s hard being a parent in America: ‘’We have not built a society that really focuses on maximizing the support for the youngest Americans or their parents so that …the typical parent is facing a lot of stresses that are going to impact their ability to support their children's mental health.’’

The impact of the first five years lasts a lifetime: ‘’We know from brain science is that the period from birth to age five is where the architecture of the brain is really set down… What children experience in their relationships and their environments and what challenges they face at the mental health level, if those are not addressed, that is actually going to impact for a lifetime that child's mental health….’’

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