• Posted April 17, 2023

For Kids With Mental Health Issues, Pediatricians Are Often Only Source for Care

With so many American kids and teens dealing with depression or anxiety, pediatricians are increasingly stepping in as mental health care providers. Now, a new study suggests they are doing a decent job -- but too few kids are being referred for talk therapy.

Researchers found that in cases where a pediatrician prescribed medication for a child's depression or anxiety, it was by and large appropriately done. Of kids who later saw a mental health specialist, few had their medication adjusted -- a sign, experts said, that the original prescription was right.

On the other hand, the study found, only one-third of kids prescribed medication also received a referral to see a therapist.

That's a concern, because if kids have symptoms substantial enough to warrant medication, they should also receive some type of counseling, said Eric Butter, chief of psychology at Nationwide Children's Hospital in Columbus, Ohio.

"A pill never taught a kid how to cope better," said Butter, who wrote an editorial published April 17 with the study in the journal Pediatrics.

It's not clear why only a minority of children in the study were referred to a therapist. However, Butter said he suspects it's because of a well-known national problem: There are too few child mental health specialists to meet the demand.

"I think that 33% figure might be higher if pediatricians had someone to refer families to," Butter said.

Study author Dr. Talia Lester agreed.

"There's such a shortage of specialists, and the need for mental health care is huge," said Lester, a clinical assistant professor of developmental-behavioral pediatrics at Stanford University's School of Medicine in California.

Because of that, both experts said, pediatricians are necessarily the "frontline" providers for common mental health conditions like depression and anxiety disorders. The new study was a snapshot of how they are doing with that job.

Lester's team pulled together medical records of nearly 1,700 children and teenagers who were patients in a San Francisco-area primary care network. All had been prescribed an SSRI medication -- such as Lexapro, Paxil or Zoloft -- for depression or anxiety. The researchers randomly selected 110 patients for a deeper dive into their records.

Overall, the study found, pediatricians adhered to treatment guidelines with those SSRI prescriptions. They documented reasons such as worsening or severe symptoms and kids having problems functioning in daily life -- including missing school and no longer doing things they once enjoyed.

Usually, pediatricians made that prescription call on their own, without involving a specialist.

"I think if anything, that's indicating that pediatricians are rising to the challenge," Lester said.

But, she added, the study also found "areas for improvement."

One was in follow-up visits after that first prescription. Overall, 62% of kids had a follow-up visit, and in about half of those visits there was no record of the pediatrician asking about any medication side effects.

Then there was the lack of referral for psychological counseling. One-third of kids were referred to an "unspecified" form of psychotherapy.

Butter pointed to the encouraging side of the findings. "Pediatricians can effectively identify mental health concerns and put families on a course to treatment," he said.

No one expects pediatricians to be therapists, Butter pointed out. They have a lot on their plates, and are not trained to be mental health specialists.

But, he said, pediatricians can address sleep, exercise and diet -- all important to kids' mental health -- and they should be able to connect families with local mental health specialists, including any school-based programs that are available.

The broader problem -- the dearth of pediatric mental health specialists -- is daunting, both experts said. Even when families get a referral, the waiting list for an appointment can be months long.

Still, they said, parents should ask their pediatrician about any additional options besides medication.

"Parents should know there is no one-size-fits-all," Lester said.

Butter stressed two broad points about helping kids manage anxiety and depression symptoms.

When anxiety is the issue, he said, kids generally learn to avoid situations that trigger the problem. But in doing so, Butter noted, "their world gets smaller and smaller." So helping kids face anxiety-provoking life situations is key, he said.

When kids have depression symptoms, Butter said, helping them "activate new behaviors" is important.

That new behavior can be simple, he noted. "It can be, 'Let's go outside for a walk before you watch that show on Netflix,'" Butter said. "It's doing something rather than nothing."

More information

The American Academy of Pediatrics has mental health resources for families.

SOURCES: Eric Butter, PhD, chief, psychology section, Nationwide Children's Hospital, chief, division of psychology, pediatrics, Ohio State University College of Medicine, Columbus; Talia Lester, MD, clinical assistant professor, pediatrics/developmental-behavioral pediatrics, Stanford University School of Medicine, Palo Alto, Calif.; Pediatrics, April 17, 2023, online