Youth in Crisis: How an Innovative Program is Addressing Pediatric Mental Health

00:00:00:18 - 00:00:20:26
Tom Haederle
Experts say at least one in five children or adolescents in a pediatric waiting room is dealing with a significant mental health problem — everything from serious eating disorders to suicide attempts. Nationwide, there has long been a critical shortage of trained care providers to meet the needs of kids struggling with these issues. And the problem is especially acute in rural areas.

00:00:20:29 - 00:00:42:06
Tom Haederle
So it's encouraging to see that the most rural academic health system in the U.S., New Hampshire's Dartmouth Health, has created one of the most innovative and effective programs anywhere to provide the tools to help.

00:00:42:09 - 00:01:09:27
Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. Sitting near the border with Vermont, Dartmouth Health serves a population of nearly two million people across many small towns in northern New England. Backed with a federal grant, Dartmouth has created a five-part virtual behavioral health training program for children and adolescents that offers care providers effective tools to engage and help guide young people through their challenges.

00:01:09:29 - 00:01:37:00
Tom Haederle
The program is called Keeping Students Safe: Supporting Youth in Mental Health Distress. In dialogue about the program with Jordan Steiger, AHA senior program manager for clinical affairs and workforce, are three experts from Dartmouth Health. Dr. Julie Balaban, child psychiatrist, Jackie Pogue, research project manager with the Dartmouth Institute for Health Policy and Clinical Practice, and Barbara Dieckman, director of Knowledge Map and patient education.

0:01:37:02 - 00:01:53:18
Jordan Steiger
Julie, I'm wondering if you can kick this off being that you are a child and adolescent psychiatrist, but we know it's been all over the news that since the start of the pandemic, a lot of children and adolescents are really struggling with their mental health. So could you kind of just paint the picture for us of what that's looking like right now?

00:01:53:25 - 00:02:21:09
Julie Balaban, M.D.
Yeah, I think there's actually been a problem with meeting the needs of children and adolescent mental health for a long time, because there's always been a critical shortage of mental health providers in general, and specifically for children and adolescents in that area of specialty. And then the pandemic really highlighted that the kids that were coming into the emergency room were seriously ill.

0:02:21:11 - 00:02:43:17
Julie Balaban, M.D.
Significant eating disorders, very serious suicide attempts. That's what was showing up during that time. And I think that really brought to light that this was an area of great need for a long time. So it's been well known that historically, that one in five kids in a pediatric waiting room, for example, will have a significant mental health problem.

00:02:43:17 - 00:03:10:14
Julie Balaban, M.D.
That number may now be higher, maybe one in four. And depending on what region you live in of course. The other piece that the pandemic played into is of course the general workforce shortage. So nursing shortage, for example, is a problem that's been affecting things like inpatient beds for kids who might need a psychiatric hospitalization. So hospitals have had to decrease their bed size.

00:03:10:14 - 00:03:34:05
Julie Balaban, M.D.
And so that led to a backlog for kids who were seriously ill, having to be in emergency rooms or even waiting at home. At Dartmouth, we had the luxury of being able to put some of those kids, at least up on a pediatrics unit, so they were around other kids and not in a general emergency department, which can be a scary place for a kid.

00:03:34:07 - 00:03:58:09
Jordan Steiger
Absolutely. And I mean, I know that this is a problem that is affecting communities, hospitals, health systems across the country. We hear it all the time at AHA. You know, we need to provide support to children and adolescents. I know you mentioned some pretty severe things like suicidal ideation, you know, severe and persistent mental illness that we know can continue to get worse when they are not treated.

00:03:58:11 - 00:04:14:27
Jordan Steiger
What I love about the work that you all are doing is that you're not just sitting back and saying, this is bad, what are we going to do? You've taken the steps to do something about it, and kind of brought your entire community and state along for the ride with you. So I would love to hear kind of what you're doing.

00:04:14:27 - 00:04:25:11
Jordan Steiger
I know that you have a virtual behavioral health training program for children and adolescents, and teaching people how to respond. Is that correct? Jackie? Can you tell us a little bit more about it?

00:04:25:11 - 00:04:49:09
Jackie Pogue
Sure. So we received a grant from HRSA around training rural behavioral health workers, very broadly defined. And we knew we wanted to focus on youth mental health. But, you know, we can't, like, grow a bunch of new psychiatrists in three years or, you know, things like that, we're trying to think creatively about where might be points of intervention that could have a bigger impact.

00:04:49:12 - 00:05:32:04
Jackie Pogue
So we met with a lot of different stakeholder groups, a lot of people from schools. So school counselors, school principals, other folks hearing about how youth mental health was impacting kids at school. So it could be things like really disruptive classroom behavior, kids who are kind of languishing, like just showing up but not thriving, right. A lot of kids wandering the hallways and hearing some of those stories, and also educators and people on the school staff, like really trying to work together for the increased severity and number of kids who were in having mental health challenges.

0:05:32:05 - 00:05:55:22
Jackie Pogue
So through those conversations, we developed, five-series training called Keeping Students Safe: Supporting Youth and Mental Health Distress. And we designed the program so that way to kind of fill some of these gaps that we heard from the schools. So they're like, well, they said they're very sick, but they went to the hospital and they sent them home.

00:05:55:24 - 00:06:17:06
Jackie Pogue
Like, why didn't they admit them? They're still so sick, or, oh, they went to the hospital and they came back and they're still really having problems, like what's going on. And so we realized there were, there are these kind of siloed systems, and to be able to share information and, you know, sort of promote more collaboration and give people more tools.

00:06:17:09 - 00:06:45:11
Jackie Pogue
What's been interesting is sort of helping people learn about all the skills they already do have, you know. I think there's a lot of fear from people that they're gonna say the wrong thing or that they don't have the tools, and not everybody is going to administer like a Columbia scale around suicide severity, right. But like especially school staff, I mean, they're amazing, you know, they're like, yeah, I talk to this kid every day.

00:06:45:11 - 00:06:55:27
Jackie Pogue
We do a check-in. We do these things like so just helping them feel more confident and that there's more details on it left out. Julie or Barb, what what else would you add?

00:06:56:00 - 00:07:26:16
Julie Balaban, M.D.
I think you did a great job, Jackie, of describing. I think what I would add is each time that we do the program, we learn from what our experience is, so that we can fine tune the content to better address what's coming up from the participants as what their needs are. And I think the other really nice aspect of the way the program runs through the I ECHO format is this all teach, all learn model.

00:07:26:19 - 00:07:55:04
Julie Balaban, M.D.
So not only, as Jackie said to people already innately have a lot of skills that they can bring. They just don't realize that it's useful. But they also all have a lot of help and support for each other and very practical resources. You know, we'll hear schools from the northern part of the state talking about something that they're doing, and then someone in the southern part of the state will connect with them offline to find out how they could implement the same thing in their school.

00:07:55:10 - 00:08:17:04
Julie Balaban, M.D.
So it's just been a wonderful way to build connections and networks that otherwise would never have happened, and all in the name of supporting youth in their schools. And our hope being that with those added resources and support, that kids will do better sooner and won't get to that severe level where they need to go to the emergency room or need to access things.

00:08:17:12 - 00:08:23:21
Julie Balaban, M.D.
But we also tell them how to handle that and what they have available to support them if they should need to.

00:08:23:23 - 00:08:52:06
Barbara Dieckman
I would agree with both of you. You know, I think that the ability to intervene in a kid's life earlier or in their where are you beginning to see some problems at school and having people that have those natural relationships with kids actually do something or be able to reach out and touch them is really helpful. I think just to decrease the demand on the whole acute care system.

0:08:52:08 - 00:09:17:26
Jordan Steiger
Absolutely. And I love, you know, through this program, you've kind of addressed some of those workforce issues that we hear about, maybe not directly, you know, but bringing people in like a coach, like a school nurse, like a principal, people like you said, Barb, that have contact with these children every day, that know them, that know their lives and can intervene, I think, takes so much stress off of the local health care system, as you all have mentioned.

00:09:17:29 - 00:09:37:07
Jordan Steiger
And I think that's so important because as you said, Jackie, we can't grow psychiatrists on trees. That's going to take a little time to build the workforce. So this is, I think, just such a great example that others can emulate and really implement in their own states. But I'd love to hear a little bit, maybe about some of the positive outcomes that you've seen.

00:09:37:15 - 00:10:21:23
Jackie Pogue
So we've done this five, it's a five-session one hour Zoom like every couple weeks. Usually. So we've run that five times. We've probably had 500 total people participate. It's been very, very popular. And some of the outcomes that we've heard, we do a pre/post course survey and we do a follow-up three months later. So things that people talked about are feeling more confident that they could intervene with a student in distress, that they knew the resources that were available and that they felt more confident interacting with youth's families as a resource and also other community resources.

00:10:21:26 - 00:10:57:29
Jackie Pogue
One outcome that we're really proud of is that, like 100% in every session, people talk about having a decreased sense of professional isolation. And so that is really powerful for us, knowing that people are, you know, just like in health care, school staff are very stressed. They've had a really hard time from the pandemic and now, and to be able to provide an opportunity for people to connect, to not feel so alone, right, that there's resources and there's hope has been really very meaningful I think for our team.

00:10:58:01 - 00:11:15:28
Jordan Steiger
That's great. I think, you know, sometimes we all get in our own bubbles and lanes and think, oh, we are the hospital. We can only solve problems for patients and families once they walk through the doors. But I think this proves that there are a lot of ways to partner with your community and to really improve the way that we respond as a whole.

00:11:15:28 - 00:11:28:20
Jordan Steiger
And I think that's really, really powerful, especially when we're talking about maybe smaller rural communities that we do know have some issues sometimes with workforce, with access, with things like that. I think this is just such a great example.

00:11:28:23 - 00:11:56:13
Jackie Pogue
Yeah. With youth mental health, it's just, it's such a crisis, right. And it's really an all hands on deck situation. And there's so many areas where people can act. And so that's really you know, when I think about the stats, it's really sobering. And then I think about all the caring school staff and community youth supporters and other folks that I have, that we've met through our Project ECHO.

00:11:56:15 - 00:11:58:09
Jackie Pogue
It really gives me a lot of hope.

00:11:58:11 - 00:12:19:09
Julie Balaban, M.D.
Yeah, I think one of the things that was an unexpected outcome for me, anyway, was hearing from the community, you know, we know this is a crisis and I come at it particularly from a clinical perspective. And what are we doing and how are we seeing these kids, and what kinds of things can we do to increase access to specialty care and all of that?

00:12:19:12 - 00:12:45:19
Julie Balaban, M.D.
And then talking to not just the schools, but particularly when we did the community programs, town libraries, we had a lot of librarians participate, and the stories that they tell about what they're doing and how they're trying to hold these kids together and what they have to manage in their setting with even less support than a school setting would have

00:12:45:21 - 00:13:09:21
Julie Balaban, M.D.
for example, it really opened my eyes to how this problem is just not just pervasive, but is really affecting people in the community so strongly, even if it's not the family member of the kid or the school trying to educate the kid. Like everybody is experiencing it, everybody is struggling. It was really something.

00:13:09:24 - 00:13:16:22
Jordan Steiger
That is. What other types of professionals were involved in that community ECHO that you ran?

00:13:16:24 - 00:13:57:03
Julie Balaban, M.D.
So we had some faith leaders from the community. We particularly ended up with our panel trying to include more of the community members for that reason, because we previously had had a lot of school people because we were dealing with school. And then of course, the hospital psychologists and myself and the typical sort of providers for kids. But we've very much have learned that if we're doing a program for a particular group of stakeholders, you need to have representation from that group on your panel, or you'll miss the boat in a number of things, even if it's just like when to schedule the sessions.

00:13:57:05 - 00:14:12:07
Julie Balaban, M.D.
So we had faith leaders, we had the coaches, we had rec department people, we had a daycare provider participate. People from some of the like, family support centers throughout the region. Those kinds of people.

00:14:12:09 - 00:14:37:15
Barbara Dieckman
You know, I would add to that, what is so good about doing this in a virtual way is that people didn't have to come to a meeting, central location. We've got mountains and you know everything else, right? And like every other rural community, there's distance, right? And there is hardship in terms of transportation and getting time off. None of that had to happen.

00:14:37:23 - 00:14:53:13
Barbara Dieckman
I mean, what we were able to do is to bring these people together from very disparate areas geographically to talk about something that they all cared about, and they all had very similar themes of need and solutions for each other.

00:14:53:15 - 00:15:12:10
Jordan Steiger
I think that's really powerful and especially like you mentioned, just, you know, addressing some of those, you know, transportation, some, you know, that distance between people, I think is something that I think many people will resonate with that are listening, you know, finding easier ways to connect people. And I think you guys have done that really, really well.

00:15:12:12 - 00:15:22:20
Jordan Steiger
As we wrap up, if you maybe have inspired somebody that is listening to, you know, implement something like this at their own hospital or health system, what advice would you give them?

00:15:22:23 - 00:15:49:00
Julie Balaban, M.D.
I would say do it. You know, we used a particular program that I ECHO program because Dartmouth has joined that group. But you can do this without any sort of a formal program. In our presentation, in our handouts, we particularly put a lot of that information because we want people to be able to emulate it within their own setting with whatever they can do and whatever resources they have, and it doesn't have to be costly at all.

00:15:49:03 - 00:16:14:16
Julie Balaban, M.D.
So I would say just jump in and do it. And I think, again, I think the important pieces are to go to the group you're trying to reach and hear from them. As Jackie talked about what they see as their needs, because we had guesses about things. But I think we did a better program because we worked from their perspective and what they were telling us.

00:16:14:19 - 00:16:24:18
Julie Balaban, M.D.
And then also to keep that good representation on your planning committee and on your panel so that you're really keeping a nice, well-rounded group going.

00:16:24:20 - 00:16:29:12
Jordan Steiger
Great, thanks Julie. Barb, Jackie, any advice you'd want to share?

00:16:29:14 - 00:16:43:01
Barbara Dieckman
Know that you can make a difference. Know that you can make a difference and just keep keep doing it. Keep improving. Keep looking for ways to hear from the people that are your audience. You can do it.

00:16:43:04 - 00:17:05:29
Jackie Pogue
I would add, you know, I think Project ECHO is a really great training platform and format, but like Julie said, you don't need to do Project ECHO to do a good program. And the things that I really value about ECHO and what we've been doing is you don't need to have a bunch of fancy experts like talking, talking, talking, right?

00:17:05:29 - 00:17:33:11
Jackie Pogue
The beauty of a more interactive, all teach, all learn there is the sense that you're relinquishing some control over your program, but it ends up providing space and being more powerful, I think. And that is, that's just how adults learn, right? Like giving each other advice and ideas and stuff that you can apply right away. So, you know, I've facilitated all the sessions.

00:17:33:11 - 00:17:52:11
Jackie Pogue
It's super fun for me to just, you know, don't know what people are going to say. And, in that way, yeah, it's just it's really rewarding. So I would say even if you're not going to use Project ECHO, I would encourage you to if you're going to do a session, have half of it be something where the audiences interacting and sharing with each other.

00:17:52:14 - 00:18:10:20
Jordan Steiger
I love that all teach, all learn model. I think that is so effective and just want to thank all of you again for joining us. I think the work that you're doing across your state is truly phenomenal. And like I said, something that others can really learn from. So we appreciate you sharing. And Julie, I know you mentioned you put some notes in your presentation.

00:18:10:20 - 00:18:17:03
Jordan Steiger
We can make sure maybe to add those to the podcast description so others can also learn from that. As long as that's okay.

00:18:17:03 - 00:18:18:01
Julie Balaban, M.D.
That would be great.

00:18:18:01 - 00:18:21:12
Jordan Steiger
Wonderful. So thank you so much again.

00:18:21:15 - 00:18:29:23
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.