'It's anxiety, it's fear, it's emotional stuff': Doctors confront poor youth mental health

Abigail McGowan went numb the day after the music stopped.

The drum major and French horn player helped lead the Anna High School marching band to the state finals in November 2021, the farthest the team had ever advanced. The next morning, after years of climbing the band ranks and months of preparing their set, McGowan realized the pinnacle of her high school music career was over.

What now?

Weekly Starbucks runs with friends and hours spent in the band room after school suddenly brought McGowan no joy. She wasn't sad, per se; she felt nothing at all.

Physicians and counselors across the country have raised alarms about the worsening mental health among children and adolescents for years. Even before the crisis was amplified by the COVID-19 pandemic, there were shortages of psychiatrists, therapists and beds at in-patient treatment facilities.

Texans have less access to mental health care than residents in any other state, according to a 2023 Mental Health America ranking. Less than 30% of Texas youth with major depression received mental health treatment.

Investments in youth mental health care are in the works. The Texas Legislature created the Texas Child Mental Health Care Consortium in 2019 to leverage 13 state universities and science centers. But the process is slow.

In the meantime, doctors and nurses say they're overwhelmed by the flood of young people suffering from anxiety and depression.

"I think the impulse is, 'Well, we need more hospitals. We need to crack down on social media. We need to do whatever.' And that's all important," said Andy Keller, president and CEO of the Meadows Mental Health Policy Institute. "But really, to me, the most important thing to do is we need to get upstream."

Pediatricians are often the first—and sometimes, only—health care contact for children but have minimal training in psychiatric care. Hospitals and clinics are experimenting with training frontline physicians and nurses to act as a safety net to catch mental illness before it becomes an emergency.

Asking the right questions

Children's Health put veteran nurse practitioner Piper Merrill through a six-month training to bolster her confidence in recognizing and treating her patients' mental health concerns.

It helped Merrill when McGowan told her that she didn't want to get out of bed in the morning, a symptom Merrill immediately identified as a sign of depression.

"Kids come in with stomach aches, and a lot of times it's anxiety, it's fear, it's emotional stuff," Merrill said. "So now I have the tools to know how to ask the right questions, because a lot of times they're not comfortable talking about their emotions or talking about their thoughts."

Children's launched the proactive pediatric behavioral health program in 2022 in partnership with the Texas-based Meadows Mental Health Policy Institute in response to the mental health epidemic primary care providers are seeing on a daily basis. About 75 providers went through the training in its inaugural year, Children's said.

The number of pediatric mental health hospitalizations rose nearly 26% between 2009 and 2019, according to one recent study. Patients often sit in emergency departments for days waiting for psychiatric beds to become available.

"The only way we're going to get ahead of all these hospitalizations is to intervene sooner," said Meadows' Keller.

"What we're doing is we're filling this huge upstream gap which is to help pediatricians identify these needs when they're small, when we can deal with them, when we can keep the child on a healthy trajectory, and we never get to a point of crisis unless we don't win with the biology," Keller said.

Traditional training for pediatricians largely focuses on how to recognize and treat different physical illnesses rather than caring for a patient's mental and emotional well-being, said Children's pediatrician Dr. Mia Best, who specializes in mental and behavioral health.

Providers going through the Children's and Meadows behavioral health training complete online courses for around six months that cover different mental health conditions and scoring systems for evaluating patients.

The program also convenes participants for group discussions so practitioners can ask questions about specific cases and bounce ideas off one another.

Additional education while juggling heavy patient loads can seem daunting, but Merrill said the investment was worth it. The objective measurements used in screening tools made Merrill more confident in her diagnosis of and treatment plans for conditions like depression, anxiety and ADHD.

"I found that once I had the language, and I also had the resources, I was less intimidated by the behavioral health issues coming my way," Merrill said.

Surveys taken after completion of the program found that trained providers increased their use of mental health screening tools, use of related insurance billing codes and calls to the Child Psychiatry Access Network, which provides behavioral health consultations to pediatricians.

The program's impact also expanded beyond just children and adolescents. Some parents were exposed to open conversations about mental health for the first time when accompanying their children to their pediatrician's office.

"Some of the things that we've seen in our kids are generational from their parents because they have not been taught to talk about their feelings," Best said. "Not only are we providing education and we're treating our kids, but it's rippling to their parents as well."

Fighting a national emergency

Mental health professionals say it will take a variety of approaches to improve the youth mental health crisis. Several of the country's leading pediatric care organizations declared a national state of emergency in children's mental health in 2021, laying out a list of changes needed to reverse the trend.

Solutions include increased funding for screening, increasing access to telehealth and using schools as mental health care sites. Integrating mental health care into places like schools and pediatricians' offices increases the likelihood that a professional can preemptively spot worrying mental well-being signs.

The first person to notice McGowan withdrawing from her friends and activities was her band teacher, who quickly brought her to her school's crisis counselor. That counselor met with McGowan a few times before recommending her parents make an appointment with their pediatrician's office.

"We are seeing an increase in the mental health crisis in schools. And that manifests as behavior problems, it manifests in learning loss, it manifests in our school safety crisis," said Jill Adams, director of counseling and social work services at Lewisville ISD.

The number of in-patient psychiatric beds is also a concern that is years in the making and one that will take years to improve. Texas identified the need for another psychiatric hospital in North Texas in 2014. Health officials broke ground on the Texas Behavioral Health Center at UT Southwestern in December 2022.

The new, $482 million hospital is set to open with nearly 300 beds in 2025. About 100 of those beds are designated for kids and teens.

Even if there wasn't a bed shortage, doctors want to avoid in-patient treatments if possible. Hospital stays, though sometimes necessary, take children out of school and extracurriculars.

Kids are coming to the hospital sicker than before, due in large part to the shortage of mental health care options, said Dr. Kia Carter, a pediatric psychiatrist at Cook Children's in Fort Worth. Because they're getting help later, treatment options are more drastic and take longer to work, she said.

Cook Children's started a mental health training program for pediatricians last year with similarities to the Children's Health initiative. The training takes place in-person over a few days and is followed by discussion groups for the next six months.

"The goal is not for our pediatricians to become child psychiatrists or therapists. The goal is to prevent the kiddos' symptoms from worsening and that early intervention is truly what helps us," said Carter, co-medical director of Cook's inpatient and consultation liaison psychiatric services.

'There is a way through it'

Behavioral health training for primary care providers won't undo the need for additional mental health specialists. Some patients, including McGowan, need care beyond what's offered by pediatricians. The training has, however, helped primary care providers feel more comfortable referring their patients to other professionals for additional treatments.

McGowan was experiencing suicidal thoughts when she started seeing Merrill, so she was referred to a partial hospitalization program where she saw a therapist daily and worked with a psychiatrist. After she finished the program, she continued to see Merrill for anxiety and depression.

"I had kind of developed an understanding of everything and actually started to believe things are going to be OK," McGowan said. "It's going to take work, but this isn't going to be my life. I think that [Merrill] put that in my head that we're going to get through this."

More than a year after seeking help, McGowan has her passion for life back. She completed her freshman year at Texas A&M University-Commerce and is studying to become an elementary school teacher. She found solace in her Christian faith, which helped her through her treatment.

McGowan also rediscovered joy in music. She took French horn lessons last semester and, though she'll be too busy with student-teaching to take them again next fall, she still plays on her own time.

"The way I experience or go through trials now is not the same as I did a year ago, and there's progress through that," McGowan said. "I want people to know that there is a way through it and that life has meaning and that you have purpose."

2023 The Dallas Morning News.

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