Pediatricians can help address child mental health demand by identifying risk earlier

The shortage of child and adolescent psychiatrists is frequently cited as a barrier to pediatric mental health care, but workforce numbers are only part of the problem, according to John Walkup, MD. The size of the pediatric mental health population means pediatricians and psychiatrists will need to work together, with primary care clinicians identifying risk and intervening earlier in childhood.

Walkup is president of the American Academy of Child and Adolescent Psychiatry and chair of the Pritzker Department of Psychiatry and Behavioral Health at Ann & Robert H. Lurie Children's Hospital of Chicago. He said approximately 20% of children experience a mental health problem in any given year, and many psychiatric conditions begin during childhood or adolescence.

Is the psychiatry workforce shortage the only challenge?

Although the shortage of child and adolescent psychiatrists is significant, Walkup said the prevalence of mental health conditions makes meeting demand particularly difficult.

"Well, I think it's important to understand that yes, there is a shortage, but the real issue is the size of the demand, that really what we're talking about is 20% of kids in any given year will have a mental health problem, and most of the mental health problems actually begin in childhood and adolescence, and pediatricians are really the front line for that," Walkup said.

Unlike less common conditions for which health systems can establish a defined specialty workforce, behavioral health problems affect a substantial proportion of pediatric patients.

"When we have a high-prevalence problem like behavioral health challenges, it's very difficult to plan for a workforce to really address that challenge," Walkup said. "And so child psychiatry and pediatrics, we have to work together to address that challenge."

What can pediatricians do before a psychiatric referral?

Rather than waiting until a child develops symptoms requiring specialty treatment, Walkup said pediatricians can begin assessing mental health risk during infancy.

"We're encouraging pediatricians to take a family history at the first well-baby visit because we know that family history of psychiatric problems is really one of the determinable risk factors for future problems in kids," he said.

Pediatricians can also discuss factors within the home that may influence behavioral development, including structure, predictability, and discipline practices.

"So by starting early, the pediatricians can really get on top of this stuff and then begin to do the anticipatory guidance based on family history and other family risk," Walkup said.

That preparation may also make the eventual transition to specialty psychiatric care easier when it is needed.

Why does earlier engagement matter?

Walkup said he frequently encounters patients who have experienced difficulties for years before reaching a child psychiatrist.

"I see kids after they've been in the system for years. They've had early challenges, early problems. They've seen other people, and I think pediatricians, because they're on the front lines, have a chance to start that process much, much earlier so that that transition actually is much, much smoother," he said.

Waiting until a family explicitly requests mental health treatment may mean clinicians have missed earlier opportunities for intervention.

"If they wait, then it's awkward. You know, they may have known something was going on for years, and then the family kind of says, Well, I think we need to do something," Walkup said. "So I think getting to them early through that pediatric practice is really the best way forward."

Can pediatricians anticipate when mental health conditions may emerge?

Knowing a child's family history can be combined with knowledge about the typical age at which psychiatric and developmental conditions emerge, Walkup said.

"We know autism often begins between zero and three, particularly if it's moderate to more severe. ADHD starts before age seven. The anxiety disorders start between six and 12. Depression and the psychotic disorders start in the mid to late teens," he said.

These patterns can help pediatricians tailor anticipatory guidance and monitoring as children develop, particularly when family psychiatric history or environmental factors indicate elevated risk.

"If you know the family history and you know the age of onset, then the pediatrician can predictably begin to work with the family and, in general, begin to forestall any kind of crisis, if you will, due to the lack of early engagement," Walkup said.

For Walkup, addressing the demand for pediatric mental health services therefore extends beyond increasing the number of specialists. Earlier engagement in primary care may help pediatricians identify risk, prepare families, and connect children with psychiatric care before their needs become more acute.