One of the most important patient populations in behavioral health is youth—kids and teens under the age of 18 who are facing major events like the pandemic atop the expected developmental challenges of adolescence.
Being a teen is complex and challenging in the best of times, especially navigating social groups and living with the emotional ups and downs that come with puberty. Youth and teens with mental health issues, such as anxiety and depression, face added difficulties.
The COVID-19 pandemic disrupted the traditional ways youth interacted with their world, moving most academic and social activities online. Digital and social media already played a complicated role in youth and teen mental health: helping maintain crucial connections with their peers though for some, negatively impacting self-esteem due to constant comparison to others, fear of missing out, or bullying.
Teen mental health issues have different signs and symptoms than those in adults, making it harder to identify and successfully engage them in care. Early identification and intervention can successfully treat teen mental health, presenting opportunities for community and healthcare delivery stakeholders to support youth mental health.
I recently sat down to discuss current trends and factors impacting youth mental health and ways that healthcare systems can innovate to reach kids sooner and more effectively.
You can listen to an audio version of my interview here:
The pandemic affected youth mental health
Q: What factors have most impacted youth mental health in recent years?
Obviously, the pandemic completely upended all our lives, but kids and teens' lives are socially driven. They were taken out of the environment where they spend the most time, have the most structure, and where they're learning. Taking those positive interactions away is just so profoundly disruptive. It really affected their level of connectivity. Some kids did well and preferred at-home learning. But a lot of kids didn't. That was a huge impact, as well as the constant stream of unprecedented impact and loss.
Because of the pandemic, they heard in the news and in their homes about loved ones dying and parents still having to go to work. There was a lot of stress related to insecurity around employment, finances, housing, and food. That level of uncertainty and constant stress together has a huge impact on kids. And then if you're a kid who is already from a stressful environment, whether there's a lower socio-economic status or a history of racial or health disparities, those effects were magnified by the pandemic.
I think the other factor that's most recent is social media. If you talk to a kid they'll say, “oh, I have tons of friends on social media." So, it is a place where kids can connect. They find their community, entertainment, and self-expression. There are positives about social media. There's also that downside. It's also a place where there's a constant visual comparison of myself versus others. And what they see on social media is not realistic necessarily. It's curated.
These lives they see are sometimes unattainable and that constant comparison can really impact kids' level of self-worth. There is some research out there where there's negative associations between screen time and lower mental health and well-being among teens; meaning higher rates of anxiety, depression with increased screen time.
Teen mental health symptoms troubled kids may show
Q: What kind of symptoms will a teen exhibit if their mental health is struggling?
There's probably going to be more anger, irritability, frustration, and physical symptoms like headache. They're also not going to be very communicative. They will have a hard time articulating what's going on, experience a depressed mood. For adolescents, it's not necessarily sadness, but lots of irritability, as well as sleep disruption and appetite disruption.
Genetics play a role in youth behavioral health
Q: What factors impact youth behavioral health besides social media and major events like the pandemic?
Another factor that could play a part into increased kid and adolescent mental health is biological, genetic factors. You've got increased pressure at school and performance activities and all of these after school activities, sports, kids doing multiple sports, and this overall pressure to achieve puts added pressure on kids.
The constant availability of media means it's hard for kids to turn those things off. They don't necessarily have enough downtime consistently where they don't have all this stimulation and input from the outside world. They just don't have that time to be calm and fully present with the people around them. That constant input isn't good for young brains.
Influences on social-emotional development
Q: How can these factors affect kids' social and emotional development?
Being a kid is already hard, especially being an adolescent is already turbulent and your emotions are up and down. It's hard finding your path, understanding who you are and where you fit in. Then if you add mental health issues or emotional issues on top of that, there's further difficult managing interpersonal relationships that are already complicated.
The other thing I think about is the fact that teenagers' executive functioning isn't fully developed. I don't think that really develops until they're in their early 20s. They don't have enough life experience for one thing, which impairs their ability to do future thinking in their decision-making, which increases their impulsivity.
And so, if you've got a teenager who is struggling, and then you add on the impaired executive functioning, those kids are potentially at risk because they may feel so horrible in the moment and helpless, like there's no way out of this. Like, “I'm not going to feel better." If they're thinking about suicide and they're impulsive that's a risky area because they're not doing that future game. They don't have that life experience. And that's a combustible combination.
I also think the intensity of today's media contributes to this kind of difficulty. Without having well-developed ways to self soothe and positive coping mechanisms, kids may turn to other things that are unhealthy. Increased disengagement and increased screen time might be the result. They're going to withdraw. And they might end up being on screens more. Then it's a vicious circle. Substance use might appear as well because they may not have had quality social interaction. Kids sometimes also have a hard time articulating what they need and how they're feeling, which might limit their ability to get their needs met, and to reach out for help when they really need it.
Challenges for behavioral health providers moving to VBC
Q: For providers moving to a VBC model, describe some challenges and some opportunities they might experience in reaching or treating these kids.
It is difficult for behavioral health provider groups to move to value-based care most of the time because they're not big enough. I have experience working at a health plan and most of the behavioral health provider networks that health plan provide are small practitioners. It's usually an individual therapist or a really small practice. So, a lot of health plans don't have value-based care with the behavioral providers in their network, because it's kind of like herding cats, there's just so many of them.
There's not a high enough patient concentration. That's just setting the context here that most behavioral health providers are not on value-based contracts. They don't see enough of a health plan's patient population, unless it's a large multi-site behavioral health clinic, as opposed to a hospital system, primary care office or primary care clinic or network.
That's a limitation inherent to who makes up most of a health plan's provider network. Most of the value-based contracting that a health plan does is with medical surgical providers instead of behavioral health providers.
Challenges to treating adolescent behavioral health
Q: What are some of the difficulties in reaching or treating kids?
It's hard to engage kids and to develop that relationship and really build trust. I think that's the number one thing. It's like you've got a kid in the office. They probably don't want to be there. Their parents are probably making them go. If they're not doing well, and feeling uncomfortable, anxious, and awkward, it's hard to get them to start talking about why they're there. So, I think the initial piece is engagement.
I have a teenager and I asked her, what's the biggest reason why kids may not want to get behavioral health treatment? She said, “They're embarrassed." That's interesting because think about where we've been in the past five or so years with behavioral health. Amongst the current generation there is more literacy and language around it, more awareness and acceptability. But even she says embarrassment is a barrier for kids getting care. Stigma is still an issue obviously and that's going to be a barrier for providers being able to reach and treat kids.
I think knowing the scope of adolescent behavioral health conditions and understanding how symptoms, like a stomachache, a headache or difficulty with sleep, could be an emotional mental health issue is important. Additionally, sometimes parents are the barrier. The parents may not be as supportive or aware. There could be stigma inside the family or inside the culture that might be preventing them from accessing care, and for providers to be able to engage and reach kids.
Keep in mind, different states have different regulations in terms of age of consent and privacy. So, in Washington State the age of consent for treatment, where a teenager can say, “yes, I will get care for my mental health condition, or no, I will not get care for my mental health condition" is thirteen.
That's really young. There are some other things in place where parents can initiate treatment. But that's a variable, where, in terms of providers being able to engage with kids and parents being able to get their kids into care, age of consent is a real factor. If you have a 16-year-old who doesn't want to get in care and they go to one session, and they're like, “nope, I'm out," that parent may not be able to force them to get back into care because they have the right to say no.
But the opposite side can be a bonus. If there's a kid whose parents may not be supportive and they're really in need, they can initiate and seek care without their parents' consent. Also, perception about privacy can be a barrier to reaching and engaging kids. Their perceived autonomy (wanting to be in charge because it's their life) can be a barrier into connecting and providing care.
What quality measures are in place?
Q: What types of outcomes or quality measures are in place to ensure this patient population receives the care they need?
There's not a ton of agreed upon outcome measures, specifically for kids. NCQA, the National Committee for Quality Assurance, has HEDIS measures, those are health effectiveness measures. There are some outcome measures for kids like depression screening, to make sure that providers are routinely and consistently screening for depression and that if they do screen positive for depression, that they're doing ongoing monitoring and assessment to see how the child is doing.
A lot of the quality measures might be medication based: antidepressant medication management and follow up, maybe some anti-psychotics to make sure that their metabolism is not significantly impaired. There's also follow up if they go to the emergency department for a mental health reason. Or if they're hospitalized, there's some specific quality measures around making sure that the providers help get them follow up appointments within seven or 30 days.
But it can also be less formalized things like making sure the providers are on value-based contract, and they're screening for mental health, anxiety, social risks and social needs regularly. If they do screen for it, making sure that they provide a referral or a connection to a community resource to help meet and remove that social need that's been identified. And then also making sure that they're completing substance use screening. And again, if they screen positive for substance use, making sure that they've got a referral to connect them to whatever care they might need. Those are some basic outcome measures for kids that can also apply to adults as well.
How payers/providers identify patients with most critical mental health needs
Q: How can payers and providers best identify patients with the most critical mental health needs?
For providers, it is screening. They need to screen often—at every appointment. And they need to screen early. Because you must catch it early before mental health issues get really impaired. You want to be able to provide interventions and education early so that it doesn't get to the point where somebody might need to be on medications and intensive therapy or need to go to the ER. It boils down to lots of screening, for everybody, universally. That way, you're not making a judgment about who might need screening and who may not.
For providers, it means having connections in the community. Whether it's a primary care provider that's providing care to the team, or whether it's a behavioral health clinic that's providing care, they need connections to resources. When an issue is identified they can quickly connect them to the need that they have. They must ensure that everybody at the clinic is involved in that process because the physician is not always going to be able to do it—they don't have time. So, it might be a social worker or a referral coordinator, but it's about having the ability to help the parents and help the kid connect to resources that they need when they identify it.
How communities can support kids
Q: What can communities and providers do to partner and support youth behavioral health?
I think sometimes it's pulling a coalition together to the communities you serve, really asking the community, parents, and schools what they think are the most critical mental health needs of the kids in that community and then working with payers and providers in the community to meet those needs. Sometimes it's difficult for a health plan to identify kids with the most mental health needs. And if they can identify it, it's already happened, because by the time you get the claim for the service that was provided, that can be a month or two later. The ER visit might be weeks old, the positive depression screen from the primary care provider has passed by the time the claim comes in. So, it's working with them to get further upstream to identify, share data, and then build services around that early data and early engagement.