The Kids Are Not Alright: NC-PAL expands access to pediatric mental health services

The Kids Are Not Alright: NC-PAL expands access to pediatric mental health services

Courtney Gardner, MSN, a pediatric nurse in Marion, North Carolina, has seen an exponential increase in depression and anxiety among her patients in the past few years. However, there are too few child mental health professionals in rural McDowell County or nearby counties — and certainly not enough to meet demand.

In other words, Gardner is often the only mental health provider available to her patients.

This is why she is grateful for the support NC-PALIt is a telephone consultation and continuing education program for primary care providers who treat pediatric or perinatal patients with mental health issues. NC-PAL is a partnership between Duke of the Department of Psychiatry and Behavioral Sciences, the United Nations University School of Medicine, and the Division of Child and Family Welfare at the North Carolina Department of Health and Human Resources (DHHS). (The pediatric side of the NC-PAL is in Duke, and the perinatal side is at UNC.)

“It’s a tremendous resource for people in primary care and in more rural parts of the state to have access to psychiatrists’ knowledge,” Gardner said. “I am able to provide care [my patients] I need it here, without having to travel or wait months for a referral.”

Access to experience

Nicole Heilbronn, Ph.D.

Duke faculty Gary MaslowMD, a child psychiatrist and pediatrician, and Nicole HeilbronnPh.D., a child psychiatristAnd the As NC-PAL Principal Investigators, or North Carolina Psychiatric Access Line; The couple also co-directed the Department of Child and Family Health and Community Psychiatry in the Duke Department of Psychiatry and Behavioral Sciences.

The NC-PAL phone line offers providers a free same-day phone consultation with a child psychologist or perinatal psychologist for questions regarding mental health or behavioral diagnoses, medications, and side effects. “It’s a timely help,” Maslow said. NC-PAL’s Behavioral Health can also suggest resources, including books, websites, or virtual exercises that providers can recommend to their patients and families.

NC-PAL also offers one-time training programs for medical practices, schools and community organizations, and a six-month continuing medical education course focused on the diagnosis and treatment of children’s mental health.

“We are working to support the whole country with a particular focus on rural counties,” Heilbrunn said. “There is not a single child psychiatrist in many counties, so how do we at Duke and UNC get that expertise outside the walls of our hospitals to support patients and doctors in their communities?”

NC-PAL is already doing just that, according to Gardner, who has used a telephone counseling line and completed a continuing medical education course. “The NC-PAL program has enabled me to serve my residents much better, knowing that I have the support and resources,” she said. “I feel like I can provide care for a big city in a small town.”

The need is increasing

NC-PAL was established as a pilot program in 2017 to address the steady rise in mental health issues among children and adolescents as well as the shortage of child mental health professionals. The program quickly expanded with funding from the U.S. Health Resources and Services Administration (HRSA) as part of a national effort to increase access to children’s psychological expertise, which tends to be concentrated in urban areas and academic medical centers.

Kendra Rosa and Inez Weaver serve as co-directors of Access Line Psychiatry in North Carolina.

In the pre-pandemic period, about one in five people under the age of 18 had mental, emotional or behavioral problems, but only about 20% of them received treatment. As many as one in three high school students experience persistent feelings of sadness or hopelessness.

Then came COVID, with its multiple challenges for children and teens – school closures, loss of sports and other activities and services, financial difficulties at home, and illness or death of family members or other caregivers. While the pandemic has been a challenge for everyone, teens have been particularly vulnerable. Now the need for NC-PAL is greater than ever.

“The next wave of the COVID pandemic is the children’s mental health crisis,” Maslow said. “It’s a real crisis.”

Since the pandemic began, Duke has seen a tenfold increase in admissions among people under 18 for medical complications from suicide attempts, with rates particularly high among LGBTQ, Black or Latinx youth. “I’ve been at Duke since 2009,” Maslow said. “We didn’t have anything like this last year.”

Heilbrunn said the Department of Psychiatry and Behavioral Sciences has seen a 60% increase in the past two years for children needing to see specialists, averaging 50 referrals a day for several months. “The number of referrals was already very high, and it increased exponentially,” Heilbrunn said. “I’ve never seen anything like this before.”

In the face of this growing demand for services, there are only 300 child psychiatrists in North Carolina. Primary care providers fill the gap by necessity.

One such primary care provider is Mary Carr Allen, PA-C, MSPH, who sees children at the Wake County Human Services Child Health Clinic. Many of her patients are children in foster care and take medications prescribed for mental illness, and some of these medications require regular blood work to check for side effects. The ability to call NC-PAL and speak to a child psychiatrist immediately, or within half an hour, about administering some of the less common antipsychotic medications increased Allen’s confidence in dealing with these cases. “It is an incredible resource FreeShe said. “We will always have questions in medicine, but I know where to go now.”

Allen also appreciates the network she gained through her participation in a free continuing education course at NC-PAL, called the Pediatric Primary Care Mental Health Mini Fellowship Program (PPP), which was developed by the nonprofit REACH Institute. The course begins with 15 hours of interactive instruction, followed by twice-monthly follow-up calls to discuss case studies. Allen enjoyed getting to know the other participants and learning from their experiences.

Gary Maslow, MD, is the principal investigator for Access Line of Psychiatry in North Carolina, which helps meet the growing demand for child mental health care.

Capacity building in primary care

Maslow believes that a long-term solution will include training more child psychiatrists and other specialists, and motivating them to work in underserved areas. But until then, families will continue to rely on pediatricians and family physicians for help, and Maslow wants to help these providers build their responsiveness.

When a doctor, nurse, or nurse calls NC-PAL, they not only get an answer to a question about a current patient’s care, but they also gain knowledge that they can use with future patients. We teach them, and then next time, they’ll be able to do it themselves,” Maslow said.

The continuing education program, REACH PPP, offers support in addition to content. Many primary care providers do not feel they have been trained to treat mental health or behavioral problems, and they do not always have close colleagues to discuss facts or challenges with. “The REACH training affects the isolation problem by supporting them,” Maslow said. “You see the changes practices go through when they get that support. There are practices before getting involved that didn’t treat teen depression at all and now they are.”

To date, the phone line has received nearly 4,000 phone calls from 51 counties in the state, and the number of new callers more than doubled between fall 2020 and fall 2021. More than 200 people have fought through the REACH PPP, and Maslow hopes 1,000 more will do so. In the next three years.

NC-PAL continues to develop its programs, launching pilot programs to provide education and training to employees in department of social services and school systems throughout the state. The NC-PAL team is also working on ways to help meet the needs of children with autism and intellectual disabilities.

Both Maslow and Heilbronn are excited about the future of NC-PAL, and are talking to primary care providers across the state to assess their needs. They are particularly excited to bring new community partners on board, such as El Futuro, a non-profit organization that provides mental health services in Durham.

“NC-PAL is a strong program and it is growing,” Heilbrunn said. “But we’re not in full bloom yet.”

Mary Russell Roberson is a freelance writer in Durham.

Kate Medley pictures

main picture: Duke Health’s behavioral health professionals help build the capacity of pediatricians and family physicians to respond to mental health needs.

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