Chad Stage and Dr. Jason Jones discuss the impact of COVID-19 on children's mental health
COVID-19 has completely disrupted children’s lives. From virtual learning replacing in-person classrooms to decreased social interaction with other children to the general fear and uncertainty of the pandemic, children have faced so much. To discover how we can best help children cope with these unprecedented mental health conditions, Emtiro’s Behavioral Health Programs Manager, Chad Stage, speaks with Dr. Jason Jones, a board-certified child & adolescent and adult psychiatrist who’s served North Carolina youth for the last 11 years.
Interview Transcription
Stage: Hello everyone, Thanks for joining us in our discussion today. My name is Chad Stage, and I am the Behavioral Health Programs Manager for Emtiro Health. The pandemic that we have endured this past year has really led to some significant changes in how healthcare is delivered. As providers we have had to adapt to meet the needs of our patients and as consumers of healthcare, we have also probably noticed some changes in how we receive our care.
As we emerge from the pandemic another threat looms in the background and that is the potential for increased risks of mental health and substance use issues especially among children. Children have had their lives turned upside down and, in many cases, might lack the coping skills, cognitive development and social supports to adjust to what we began calling the “new normal” virtual schooling, lack of meaningful social interaction with peers and the fear of what was going on around them in the world.
Given these risks we felt it would be helpful to talk with an expert on such matters and get some insight into how things have changed, what we need to look for in our patients and our children and provide some tips on how to manage these rising risks in our new normal. I would like to introduce our expert for today Dr. Jason Jones.
Dr. Jason Jones is a board-certified child & adolescent and adult psychiatrist who has provided medical leadership and clinical care to youth in North Carolina for the last 11 years. Since 2016, Dr. Jones has been the Medical Director of Family Service of the Piedmont, where he led the development of a specialized child psychiatry clinic dedicated exclusively to children and adolescents. The High Point Center for Child Wellness opened in March 2020 and has provided uninterrupted services throughout the pandemic. Dr. Jones provides direct care at the clinic, as well as supervision and clinical oversight of therapists, medical staff, and nurse practitioners. He has an extensive history of teaching child psychiatry in academic and other settings, and he was formerly the medical director of Partnership for Community Care and a Network Psychiatrist for NWCC. Dr. Jones Welcome and thank you for participating.
Dr. Jones: Thanks Chad it's good to be here.
Stage: So, with that let just jump right into some of the questions we have for you Dr. Jones. The first one is and as I stated before this past year has been somewhat unprecedented, what are some of the major themes that you’ve seen as a child psychiatrist in your patients?
Dr. Jones: We’ve seen a lot of stress, and the themes of loss, risk, and adaptation. As we move toward a new normal and a new way of doing things, there have been a lot of challenges in terms of how we understand child mental health and the ways that we can address it. Loss is a big theme of the pandemic. We have had a loss of our connections to other people, and the literal loss of more than 600,000 of our fellow Americans that have died from COVID-19, some of whom are parents of children we serve. The loss of school, educational progress, and academic advancement. There is also a financial loss that individuals and families have suffered during this pandemic.
Another theme is risk. We have the risk of physical health problems--the known issues that can result from COVID-19--but also behavioral health concerns, which include both immediate, direct effects of the virus as well as the impacts of our social changes, and then the longer terms risks that you talked about.
And then there's adaptation. Adaptation to the new normal is the other theme that I have seen. The way we consider the delivery of behavioral health care, the ways that mental health is considered more paramount, discussed more frequently in our media and among our fellow citizens. I think there is some good news in the reduction of stigma against mental health and receiving mental health services.
Stage: That leads us into the second question I have for you Dr. Jones. Given these changing landscapes of delivery of healthcare and some of the rising concerns that I think we are starting to hear a little about in the media do you see an opportunity to highlight the importance of mental health post COVID?
Dr. Jones: Yeah definitely. The awareness piece--there's this concept called the “identified victim effect” that once people they know someone that has been a victim of mental illness or has been suffering with mental illness, that brings awareness and acceptance on a personal level. And so, unfortunately there is a lot more mental illness, but it's creating a lot more understanding and acceptance of getting help, and some decrease in stigma for sure. So, I do see opportunities--another example is mental health parity in which behavioral health care may be reimbursed at the same rates as physical health care, that’s a real important opportunity.
Stage: Yeah great. So, we’ve talked a little bit at a 40,000-foot view of how healthcare has changed. Can you give us some examples of how your agency has had to adapt in how you treat your patients and meet their needs over this past year?
Dr. Jones: Yeah, so, we opened right at the beginning of the pandemic, I mean our timing could not have been more interesting. We had to rapidly adapt our telehealth capacity. We had to do all the typical things with the 3 “W’s”, temperature checks--it did really create a challenge for us in just the navigation of the logistics of it all. The telehealth piece probably is the biggest adaptation that we made. Telehealth really does break down a lot of barriers and challenges, for instance when it comes to transportation and attending appointments. It also proved crucial and necessary when you have risks of contamination or someone in the household has tested positive and they literally cannot come into the office. Another piece is increased recognition of the impacts of stress on both adults and for children. Anything that happens to parents can also trickle down to kids.
Stage: True. You mentioned telehealth and I think the physical health care side has also seen an increase in utilization of that technology-based healthcare delivery. As we move forward it seems like this concept of using telehealth is probably going to stay with us, do you have any concerns about how that might impact or things that providers should be aware of that may be downsides to telehealth care delivery?
Dr. Jones: Yeah, I think it is definitely a mixed bag. There are a lot of great things--there is some evidence to show that telehealth reduces disparities. It does allow for some increased access to healthcare. There is a greater show rate for appointments in mental health clinics, so you can see a few more patients a day. It definitely breaks down barriers for transportation, and stigma, as some people don’t want to be in a waiting room in a behavioral health center for fear of being seen by neighbors or friends. So, the ability to be able to dial into a behavioral health care appointment in the privacy of your own home is definitely has opened the doors for some. Unfortunately, however, telehealth is not a panacea here, its not going to fix some of the fundamental issues that dissuade people from getting behavioral health care. Number 1 we do not have enough providers, the shortage of providers that existed before the pandemic has continued and telehealth does not increase the number of providers it just maybe allows providers to see a few more patients per day. The increase in mental health problems that we’ve seen and increased need for services has far outpaced any added capacity that may have come from telehealth. Telehealth also does not address financial barriers, be they insurance deductibles or copays or other financial barriers that prevent people from getting the needed behavioral health care--telehealth doesn’t help that. Telehealth also doesn’t help those that aren’t connected, some 7-10% of the population that does not have the internet access. Or there are individuals who are less technologically savvy and may not be able to utilize the telehealth. There are some estimates that up to 20% of individuals over the age of 65 may be dealing with mental health concerns and this is a population that isn’t naturally going to easily adapt to telehealth. The other concern I have about telehealth is confidentiality and privacy issues. With all the stuff in the news about hacks and data leaks people might have real concerns about sharing their most personal intimate details on their laptop. There is also a concern that when we as behavioral health professionals are meeting with our clients and they’re in their home, who is listening? Particularly when we’re working with kids, are the parents just outside the bedroom door listening in? That confidential space that’s required in order to provide effective behavioral health care can be threatened and it takes some extra steps to make sure that this is not only HIPAA compliant but a safe and secure space where the individual can share what they need to share.
Stage: Yeah, do you feel like there is any chance of that telehealth service being over utilized due to the convenience that it presents to the actual clinician or practice? Because I think there is some benefit to a face-to-face encounter at times. Are there any downsides to providers/practices over utilizing due to convenience?
Dr. Jones: I think there are some segments of the population, some clinical scenarios if you will that require a face-to-face intervention. Particularly in our clinic when we work with younger kids, kids under age 10, there’s a limit to how effective a telehealth appointment can be. When there are complex family dynamics, when you have parents sharing custody, when other caregivers are involved, and certainly if you’re in a situation where department of social services is involved--in these kinds of cases you really do need an in-person face-to-face encounter. For very complex situations, to be able to see the family dynamics it really does benefit people to come in face-to-face. Now all that being said I will say that the evidence seems to show that tele-therapy is just as good, or is at least not any worse, than face-to-face therapy, and so older adolescents and the adult population can use telehealth effectively for therapy and there is little risk of over utilization in that sense.
Stage: I think we have touched on this a little bit in some of the previous questions, the pandemic obviously has put a different mindset in the clinical space, what opportunities do you see that behavioral health has to finally get the attention it deserves in the healthcare space?
Dr Jones: It is really recognition and awareness. You know the Pandemic had profound effects on our population. The disconnection and isolation. The statement “mental illness thrives in isolation” suggests that disconnectedness really allows mental illness to flourish. We are seeing increased rates across the board with almost every psychiatric condition. Increased anxiety, panic, OCD, trauma related disorders, depression, substance use and overdoses--there has been a sharp increase in ER visits for adolescents during the pandemic, around a 30% increase--eating disorders are increased around 30% in girls and a couple of percentage points for boys as well. In one estimate, OCD has increased 40% in teenage girls. We are seeing this increase across the board for most kinds of conditions. I think more and more families are becoming aware of it, they are seeing the impacts, and we haven’t even touched on the impacts of school and school closing and lack of adequate educational engagement from our children. I mentioned earlier that telehealth therapy probably isn’t any worse in many cases versus face-to-face therapy, well, it does look like virtual schooling is worse than in person attendance in school. There appears to be less engagement, less academic advancement, and more academic loss--that loss in some cases is going to be very difficult to overcome. There is an estimate that we have lost on average 5 to 9 months of academic progress in our youth. The virtual learning that occurred for the predominance of our population had profound effects. I think we are all feeling it, we are all more aware of it, and now we need to be able to have the systems and the capacity to deal with it.
Stage: Knowing that this tidal wave, and the picture behind you is symbolic of that, the tidal wave of mental illness especially in children is coming, what are some tips you may have for primary care practices that are seeing children coming out of the pandemic and being able to identify what is going on with their patients?
Dr. Jones: This is a real challenge for our primary care colleagues. They are on the front lines of this, they are the most trusted providers for most of our families. There is evidence to show that the average American will accept an antidepressant prescription from their primary care provider, but they would not accept one from a psychiatrist, they would not go to see a psychiatrist. There is a need for primary care providers to be aware of this tidal wave that’s coming, and be prepared. I think the evidence shows that in primary care settings mental illness can be screened for using standardized screening instruments, at the very least a screening process that looks at depression, anxiety, and substance use. There are validated scales that are relatively easy to complete, which can be completed before the physician/provider sees the patient. Now, once you screen for something then you need to know what to do about that. Where to refer, whom to refer to--that’s where it starts to get tricky, as mentioned people are resistant to referrals to behavioral health. They will ask their primary care provider “Well can’t you just do this for me?” Finding ways to empower and support primary care practices to manage all of this is crucial. As you know there are lot of models that are being used to try and integrate behavioral health with physical health care and some of our payor systems are now aligning with that, so I see this as an opportunity. Whether its collaborative care, integrated care, or co-located care, there are several different ways that this can be implemented. The evidence seems to show that if you dial psychiatric expertise into a primary care setting that can be an effective way to get help to people that otherwise would never receive help. I think that we should be looking at our systems, how we can integrate behavioral health and physical health and recognize while we are doing that, we must beef up our behavioral health care system. We must have more resources, more providers, and we need systems of care not just a few more individuals hanging a shingle--we need systems to take care of everyone. This is something that requires large scale action on a societal level.
Stage: I am very glad to hear you say that. I have worked with a lot of primary care practices to implement some of those models that you suggested and my hope that the awareness that comes from this we will get a broader adoption of integrated care within the primary care setting. On the other end there are parents who are going to have to deal with or may not be aware of the changes in their children. What are some tips or concerns parents should be on the look out for in their children? And when should they seek help from their PCP or behavioral health specialist?
Dr. Jones: This is a real challenge, because parents are also going through a lot of stress right now, the effects of the pandemic and all the other things going on in our society right now is affecting parents. It is making it hard for parents to be overly attuned to their children’s needs. I think most parents, if they are attuned to their children they are aware of when there are problems, and they probably know when to ask for help. So I would just say listen, genuinely listen to your children, sit down and hear them out. Normalize that change is stressful. Anytime we must adapt, whether it's to virtual learning or virtual birthday parties, that change can be experienced as stressful. Validate that for your child. Help your child to identify their feelings, help them talk about and identify their feelings. The concept of social emotional learning is crucial and needs to be developed during childhood. Those who do not develop skills during childhood often lack them as an adult. There are adults who can’t identify their feelings, can’t label their feelings. We need to help kids to do that. If we help them express themselves, and if we are truly listening to them, then I think most parents will know when to ask for help. Parents may ask for help in different settings--they may turn to religious supports, friends, family, primary care providers, case managers, and others to get the guidance that they need.
Stage: Dr. Jones that is all the questions I have for you today. I really appreciate your insights and expertise into this, and I hope that some of things that we have talked about today can be implemented and we can see some real change.
Dr. Jones: Thanks Chad. I appreciate the opportunity, and I do think we have an opportunity on the largest levels here in this country to make some fundamental changes. It does require some widespread collective effort that will involve law, politics, economics, healthcare systems and providers on the front lines that are doing the hard work. I hope that we are all in it together and we can see some fundamental changes for generations to come.
Stage: Absolutely. Thank you so much
Dr. Jones: Thank you