As the COVID-19 pandemic wanes with a tangible end in sight, assessing its aftermath is only beginning. In its wake is a plethora of pressing matters, many of which have been amplified by COVID-19. “A big, bright light is now shining on all these inequities that existed prior to COVID,” notes Michelle Durham, MD, MPH, child and adult psychiatrist at Boston Medical Center. One issue in particular holds youth and adolescents in its grip: a longstanding mental health crisis worsened by the pandemic.

The crisis before COVID-19

The Centers for Disease Control and Prevention report suicide to be the second leading cause of death among children and adolescents younger than 18. The pervasive issue is underscored by several factors that have contributed to mental health struggles: delayed reporting, barriers to access and racism and discrimination. “In general, most kids will say they were 12 or 13 when they first noted something was not right,” explains Durham. “There’s a gap between kids knowing that something’s not right and when they actually get help. That gap is about 10 years, which is pretty substantial.” Other possible factors that play a role in delaying care include the stigmatization of a mental illness, downplaying one’s own symptoms or not understanding mental health issues.

Mental health conditions are more prevalent for children raised in poverty and exposed to adverse circumstances. Among these, Black and Latinx children are disproportionately affected. Magnifying this inequity are challenges surrounding access to mental health care—due to low reimbursement rates and added administrative burden, many private practices do not accept state- and government-issued health insurance like MassHealth. “As a society, we have never invested in equitable reimbursement for mental health the way we do for physical health so it’s unfortunately no surprise we are in the place we are now,” says Durham.

In Massachusetts, a vast majority of children younger than 18 living in poverty or low income households have MassHealth—88 percent and 81 percent, respectively.

“There was always a huge access issue even prior to the pandemic that grew even wider for kids who were low income or people of color,” Durham notes. “Often, those patients come to BMC. When they do, it’s usually in crisis or it’s been years of something going on. Treating severe cases requires substantial teamwork to figure out how to best help the patient and their family.”

Compounding the issue of access is a shortage of child psychiatrists. A 2016 study in Pediatrics determined there were around 9.75 child psychiatrists per 100,000 children (0-19). The American Academy of Child and Adolescent Psychiatry estimates there needs to be 47 per 100,000.

Durham also recognizes that sometimes treatment is not successful or delayed because of the role racism and discrimination play in how people perceive a child and their behavior. This is especially noted in the school setting.

“Those who act out or have a lot of behavioral issues in school end up getting disciplined instead of trying to understand why the behavior is happening in the first place. Kids’ behavior means a lot in the mental health world because they don’t always have the words to express what’s going on,” explains Durham.

She says biases toward students of color have impacted mental health. “Studies show racism and discrimination toward Black and brown kids, even as young as preschool age, in the preferences that teachers, teacher aides and other school administrators have had for certain kids.”

The pandemic creating more instability

 As the world shuttered to reduce the spread of COVID, the pandemic chipped away at the critical yet fragile foundation of youths’ lives. Coping with school closures proved to be particularly significant. “School is a pivotal time in everyone’s life,” Durham explains. “It’s a key place for social learning. The loss of those social connections—which are critical to who we all are as individuals—was profound.”

Stressors also permeated their home lives. Families contended with socioeconomic factors that indirectly impact a youth’s mental health, like employment.

“A family living paycheck to paycheck is already dealing with economic instability before the pandemic. If an employer decided to reduce hours due to COVID, all of a sudden a family’s livelihood’s at stake,” Durham says. “Essential workers had to go to work every day—they could not adhere to quarantine guidelines. Many of the families we see live in multi-generational homes. There may have been several family members who continued to work [outside the home] at the risk of exposing their families to COVID-19.”

Amidst bearing witness to day-to-day struggles, children were also subjected to seeing loved ones get sick with COVID. As COVID death rates soared across Black and Latinx populations, many children suffered profound loss in their families and communities.

Nationally, cases of depression, anxiety and suicidal ideation went up drastically. The demands on the already sparse and overburdened pediatric mental health care landscape have been unprecedented—especially in the emergency department setting.

“What we’re seeing right now is the outcome of people not having a continuum of access pre-pandemic,” Durham says. “Maybe you weren’t feeling great and wanted to get help but you likely couldn’t find someone. So then those symptoms just get worse and worse to the point where we have to do what we call the highest level of care [known as inpatient psychiatric locked units].”

A sharp increase in severe mental illness led to a shortage of inpatient psychiatric locked units. “We already had a limited number of beds but due to COVID distancing requirements, there were even fewer,” Durham explains. “We have a lot more people presenting with depression, anxiety, suicidal thoughts and psychotic symptoms—people who need inpatient care. So now we’re definitively in a crisis.”

There was also higher demand for child psychiatrists in the outpatient setting. While the ability to offer telemedicine appointments boosted the number of patients that could be seen by BMC’s child psychiatrists, Durham observed digital inequities: Patients struggled with having the proper accommodations like a laptop, internet or a private space to talk. A patient’s living situation also impeded providing the best care possible. “Telemedicine offers a window into the home and allows us to see another element of who the patient is,” Durham says. “However, that can be hindered when a patient doesn’t have a private space to talk openly—especially when there’s conflict in the family or home.”

Pathways to improving care

 BMC is addressing the pediatric mental health crisis through three tenets: advocacy, workforce development and a prevention and promotion framework.

Durham is quick to point out that advocacy efforts must be multi-faceted–“We need to be more vocal in our city, government and communities about equitable, accessible treatment- no matter who you are, where you’re from nor your ability to pay, that should be the standard.” She suggests expanding BMC’s current efforts—BMC’s Government Affairs is actively involved at the local, state and national level to improve access and reimbursement in mental health for the hospital’s Medicaid/medicare population —by calling on all practitioners to fight for equitable reimbursement for mental health care. She also notes that advocacy also comes in the form of making space for community voices to be heard. “We also have a responsibility to be quiet and listen to our communities so we can understand what needs to be done or what we can do differently,” she says. “That is how we will best serve all people in the health system and, by way of that, the mental health needs of children.”

The Department of Psychiatry’s workforce recruitment efforts are greatly influenced by a commitment to creating a culture of representation and inclusiveness. A patient who is able to identify with their provider on a cultural, spiritual and/or personal level helps build trust and feelings of safety—critical components of a positive patient-provider relationship which prove to be invaluable in mental health care where sensitive information is disclosed. “We are very intentional in recruiting folks who reflect our patient population—there is no better place than BMC to recognize the importance of this,” she explains. “It’s important for a patient to feel their provider has shared experiences and ‘gets it.’”

BMC’s general psychiatry residency program, psychiatry fellowship programs, psychology intern program and licensed mental health counselor program all share a key focus on building a diverse workforce. Durham also aspires to establish a two-year child and adolescent psychiatry fellowship program. She notes its goals would be two-fold: “We could definitely use more child and adolescent psychiatrists and we want people who understand how to work with ethnically, culturally and linguistically diverse patient population.”

Another crucial step is the prevention and promotion framework. “Reaching a point of crisis is not the goal,” Durham says, emphasizing the need for more mental health care “entry points” throughout the health care system. “The goal is to invest [in mental health] early on and meet patients where they are.” Durham and her colleagues started the grant-funded TEAM UP for Children initiative, working with federally-qualified health centers (FQHC) to co-develop a model that integrates mental health and physical health in the pediatric primary care setting. Now in its seventh year, the initiative builds on the longstanding relationship between families and their pediatric primary care provider. “Families often turn to the pediatric primary care provider first when something is not right, making it the ideal place for this intervention,” Durham explains. TEAM UP expands the medical home to include community health workers and behavioral health clinicians.

“For a child to be in contact with a behavioral health clinician the same day is vital—that doesn’t happen in any other space,” Durham says. “The community health workers help close the gap between primary care providers and the patient because most are from the communities where the FQHC is located. Many are bicultural or bilingual. They ‘speak the language,’ if you will, of the family in ways that a primary care provider may not. They help families understand how important mental health services are.”

In keeping with the mission of meeting patients where they are, it is essential to step beyond hospital walls and work closely with community-based organizations. “That way, we’re starting at the prevention end of the spectrum, not the acute end,” Durham notes. “We need to open lines of communication about mental health and provide resources.” The approach calls for outside-the-box thinking. One colleague is working with local churches as a means of breaking the stigma around mental health and building education and awareness. Through a partnership with the Boston Public Health Commission, a BMC child and adolescent psychiatrist consults with therapists embedded in Boston schools on matters related to students’ mental health—something especially important as schools return to full-time in-person teaching in the fall.

“What BMC has done, and continues to do, is push boundaries,” Durham concludes. “Kids are part of systems—family, community, health care—and we need to invest in all of them. If these systems are not alright, the kids will not be alright.”