Dr. Mahela Ashraf, a Consulting Psychiatrist for MC3’s perinatal patient care service, was interviewed by TV6 in the Upper Peninsula regarding the importance of women’s mental health. She highlighted MC3 and its role in supporting providers statewide who are treating perinatal patients with mental health concerns.
The following story, written by Meredith Bruckner, extensively quotes Dr. Joanna Quigley, a consulting psychiatrist for MC3.
Link to original article on All About Ann Arbor’s website
ANN ARBOR – Another school shooting has rocked the state of Michigan just over one year after the deadly shooting at Oxford High School.
On Monday night, a gunman entered two academic buildings on Michigan State University’s campus and shot several students, killing three and critically wounding five.
The suspect, a 43-year-old male with no affiliation to the university, died of a self-inflicted gunshot wound off campus hours after the initial attacks, authorities said.
Classes and all campus activities have been canceled at MSU for 48 hours, and all K-12 schools in the East Lansing Public Schools District are closed on Tuesday.
As students and families across the state wake up following an incident, it can be difficult to avoid exposure to the topic on social media, television and radio.
Limit screen time
What’s the best way to help young children and teenagers process such traumatic news?
Joanna Quigley, a child psychiatrist at Michigan Medicine said it can take a long time to cope with the grim reality of school shootings.
“The biggest things that adults and our communities can do right now are to provide consistency and structure, to keep open lines of communication, and to find time each day to check in with one another,” Quigley said in a statement in the immediate aftermath of the Oxford High School shooting. “Make it clear you’re available to answer questions about what happened, but make sure the child isn’t overexposed to the media coverage of the event, or to social media posts about it.”
She said that being exposed to news and coverage of the event on social media can cause a child to be retraumatized, so avoiding digital devices is recommended.
Quigley recommended that teenagers refer to “When Terrible Things Happen” by the National Child Trauma Network as a tool to help them reduce the negative effects of major traumatic events.
Other resources she recommended include the Resources for Families site from SAMHSA, a federal agency and the disaster, violence and trauma resources from the American Academy of Child and Adolescent Psychiatry.
Keeping communication lines open
Quigley acknowledged that parents sometimes avoid discussing a traumatic event altogether as a way to cope. This, she said, can make a child feel like they can’t talk about it when they’re ready.
“Grownups should name the emotions they’re feeling about this situation, especially with teens,” she said in a statement. “Sometimes older children and teens aren’t ready to name the emotions they’re feeling or discuss them proactively, but if they hear that others are feeling them, they may.
“Even if say they don’t have questions or don’t want to talk right now, let them know you have an ‘open door policy’ if they do want to talk, which could be a week or two from now, or may be prompted by more information coming out about the incident. It’s important for them to know that the adults in their lives are available to them on an ongoing basis.”
She added that consistency in routines is extremely important, including spending quality time together as a family, keeping regular schedules and healthy sleeping and eating habits. School is also an important source of stability for children, with many resources available to students, she said.
Reporting a problem
If you suspect a teen’s personality or behavior has changed and become concerned, speaking up is the best solution, said Quigley, who added that several mental health conditions like schizophrenia and depression tend to peak during the teenage and young adult years. Such concerns should be brought to a child’s pediatrician.
Anyone concerned about school safety in Michigan can contact the OK2SAY Tip Line at 1-855-565-2729, text to 652729 or email to ok2say@mi.gov.
Additionally, the National Suicide Prevention Lifeline is available at 1-800-273-8255 or via live web chat should someone voice concerns about hurting themselves. Crisis lines for each county in the state are listed here.
Dr. Nasuh Malas, Consulting Psychiatrist for MC3, was featured on the Pediatric Meltdown podcast episode titled “Somatic Disorders and Medical Child Abuse aka Munchausen by Proxy: Guidance for Clinicians.”
Dr. Nasuh Malas, a consulting psychiatrist for MC3, will serve as a member of the Commission
LANSING, Mich. — Today, Governor Gretchen Whitmer announced appointments to the School Safety and Mental Health Commission.
Created by the FY22-23 School Aid budget, the School Safety and Mental Health Commission will collaborate to provide recommendations to reduce youth suicides and strengthen the mental health of school-aged children, adolescents, and their families through a comprehensive, statewide approach. The Commission will seek input from educational professionals, mental health professionals, and organizations from across this state to suggest approaches to identify and support students at risk of behavioral health issues.
“Every kid in Michigan has a birthright to a phenomenal public education and we need to work together to ensure they can thrive by investing in their overall well-being, including mental and behavioral health,” said Governor Whitmer. “Since I took office, we have enacted four balanced, bipartisan education budgets including the highest state per-student funding ever and dedicated resources for school safety and mental health. Today’s appointees to the School Safety and Mental Health Commission will ensure that we use our resources effectively to keep our kids safe and learning in-person.”
“As chair of the Michigan School Safety Commission and deputy director of the Michigan State Police, which houses the Office of School Safety, I am committed to working collaboratively to do all we can to improve school safety in Michigan,” said Lt. Col. Chris Kelenske, Deputy Director of the Michigan State Police. “The recent investments in the bipartisan state budget for school safety will help us shore up on-campus safety, and the work of the School Safety and Mental Health Commission will ensure that the resources are delivered where they will have the greatest impact for our kids. The MSP stands ready to utilize all available best practices to keep our children safe and focused on learning.”
“As school leaders, we are focused on fostering a safe learning environment for all of Michigan’s students, teachers, and staff,” said Dr. Tina Kerr, Executive Director, Michigan Association of Superintendents & Administrators. “We appreciate the collaboration between Governor Whitmer and the Michigan Legislature on this year’s education budget and know our districts around the state will continue to use every resource provided to supplement student learning, improve school safety, fund mental health supports, and help our students grow and thrive.”
The Commission consists of individuals appointed by the Governor and individuals appointed from recommendations by the Senate Majority Leader, Speaker of the House, House Minority Leader, and Senate Minority Leader. Additionally, designees from the Department of Education, Michigan State Police, and the Department of Health and Human Services will serve as members of the Commission. Appointees will bring a wide-range of experience including mental health treatment, school-threat assessment, law enforcement, parents, and teachers.
The following individuals will serve as members of the School Safety and Mental Health Commission:
Daveda J. Colbert, Ph.D., of Farmington Hills, is the superintendent of the Wayne Regional Education Service Agency. She holds a Bachelor of Science in Accounting and Business Administration from Southern University at New Orleans, a Master of Arts in Teaching from Wayne State University, and a Ph.D. in Education from Oakland University. Dr. Colbert is appointed to represent members with a background in school administration. She will serve for a term commencing October 1, 2022, and expiring October 1, 2026.
Patrick R. Green, of New Baltimore, is the marine enforcement officer and reserve police officer for New Baltimore Police Department. He holds an associate’s degree in general studies from Macomb Community College. Mr. Green is appointed to represent members submitted by the Speaker of the House who are parents. He will serve for a term commencing October 1, 2022, and expiring October 1, 2024.
Alyse F. Ley, M.D., of Okemos, is a physician and director for Child and Adolescent Psychiatry Fellowship Program at Michigan State University where she also serves as the residency education director for the Department of Psychiatry. She is also an advisor to the National Policing Institute Foundation Center for Mass Violence Response Studies. Dr. Ley holds a Bachelor of Science in Psychology and a Doctor of Osteopathology from Michigan State University. Ms. Ley is appointed to represent members with experience in school-threat assessments. She will serve for a term commencing October 1, 2022, and expiring October 1, 2026.
Nasuh Malas, M.D., of Ann Arbor, is a clinical associate professor in the Division of Child and Adolescent Psychiatry and the Department of Pediatrics at the University of Michigan. Dr. Malas also serves as the director of the Pediatric Consult and Liaison Psychiatry Service and chief of the Child and Adolescent Psychiatry Service for the C.S. Mott Children’s and Women’s Hospital. He received his Doctor of Medicine, Master of Public Health, and Bachelor of Science in Medical Microbiology from the University of Wisconsin. Dr. Malas is appointed to represent members with experience in the provision of inpatient treatment to children under age 18. He will serve for a term commencing October 1, 2022, and expiring October 1, 2026.
Jason Russell, of Middleville, is the founder and CEO of Secure Education Consultants, a consulting company that seeks to improve risk management and security within organizations and primarily in school districts. He holds a Bachelor of Arts in Criminal Justice from Western Michigan University and a Master’s in Security Management and Criminal Justice from Michigan State University. Mr. Russell is appointed to represent members submitted by the Speaker of the House with a background in law enforcement. He will serve for a term commencing October 1, 2022, and expiring October 1, 2024.
Jennifer Taiariol, Ph.D., of South Lyon, is the school psychologist and director of student services for Livonia Public Schools. She earned her Ph.D. in Educational Psychology and Master of Arts in School and Community Psychology from Wayne State University. She also holds a Master of Arts in Applied Behavior Analysis and Bachelor of Arts in Psychology from Western Michigan University. Dr. Tairiol is appointed to represent a member submitted by the Senate Minority Leader who is a school psychologist or psychiatrist. She will serve for a term commencing October 1, 2022, and expiring October 1, 2026.
Rosa M. Thomas, of Milford, is the chief operations officer for Honor Community Health, a non-profit community healthcare center that includes school-based health centers. She holds a bachelor and master’s degree in clinical psychology from Inca Garcilaso De La Vega University in Peru. Ms. Thomas is appointed to represent a member submitted by the House Minority Leader with experience in school mental health. She will serve for a term commencing October 1, 2022, and expiring October 1, 2024.
These appointments are not subject to the advice and consent of the Senate.
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The following story was written by Deena Centofanti. It extensively quotes Dr. Nasuh Malas, a consulting psychiatrist for MC3.
Link to original article and video on Fox 2 Detroit’s website
Excitement, sadness, anticipation, fear, anxiety – this time of the year is filled with emotion.
Summer is ending, for kids a new school year is beginning, and no matter what the age, for both the student and parent, this can lead to some anxiety. The doctor is in to help all of us get through it.
“There are a lot of potential stressors that can occur throughout the year. One is peer stress and social stressors of just adapting to the day to day. And that can include bullying, involvement in romantic relationships, relationships on the sports field or an extracurricular. Also, academic pressures, internally or societal,” said Dr. Nasuh Malas, a child psychologist at University of Michigan Health.
Malas said it’s important to talk to children and figure out what they are thinking.
“It can be really hard to reassure children and adolescents about some of the stressors that kids just experience in school these days, whether it’s bullying or violence, or other unexpected challenges that occur, it’s hard to really anticipate all that all you can do as a parent, is create an open door policy where anything that the child wants to bring to you, they can bring it to you in a loving and nurturing way,” Malas said.
Pre-pandemic data from the CDC finds that close to 1 in 10 children between the ages of three and seventeen had diagnosed anxiety. That’s nearly 5.8 million children in the United States. Malas says anxiety can be healthy but it can also be concerning.
“It’s when that anxiety becomes more significant and starts to really affect lots of different areas in our life, whether it’s not being able to be involved in social relationships, struggling completing school tasks, showing behaviors that are really disruptive or problematic. Those behaviors and those emotions can sometimes be really impairing for a child. And when that occurs, that’s when you want to call a specialist to get help,” Malas said.
Malas says there are factors we can try to control that help support good mental health, good sleep, nutritious food, being active, and having a good sense of self-worth. Those are good behaviors to model as adults.
If your child is experiencing a mental health emergency or suicidal thoughts, the new 9-8-8 hotline can provide support. Parents can also find more resources on child anxiety by visiting the American Academy of Child and Adolescent Psychiatry: Family Resource Center on Anxiety Disorders.
The following article was written by Cecilia Warchol and published by the Michigan Health blog. It extensively quotes Dr. Nasuh Malas, a consulting psychiatrist for MC3. Link to original article
The summer months may seem a little hectic with kids home from school and new schedules to adjust to. However, it’s actually a great opportunity for you to pay closer attention to how your children behave, especially during the hours when they would normally be in a classroom.
And as summer winds down, it’ll be important to also take note if your kid seems anxious about returning to school.
For some, it could be a healthy form of anxiety in the form of excitement and anticipation for what’s to come in the new school year. Yet, for others, it may signal a more serious sign of anxiety.
But how can you tell the difference between “normal” nerves and something more serious? University of Michigan child and adolescent psychiatrists, Gregory Hanna, M.D., and Nasuh Malas, M.D., MPH, who is director of pediatric consultation and liaison psychiatry services at University of Michigan Health C.S. Mott Children’s Hospital, help answer that question along with screening guidelines, what “healthy” anxiety looks like, when to seek professional help and how to talk about anxiety with your kids.
“Anxiety is the experience that youth may have when they have distressing thoughts, worries or negative perceptions about a future or anticipated event and/or may have a limited capacity to manage distressing thoughts or worries,” said Malas.
In small doses, anxiety may be motivating, but in severe cases, it can impact many aspects of a child’s life—school, medical care, friendships, family interactions—and become debilitating.
Signs of anxiety can range from child to child.
Some physical changes can include muscle tension, headaches, stomachache, restlessness, feeling their heart racing and sweating. Behaviors such as avoidance, tearfulness, withdrawal from activities, panic, irritability, or expressions of fear—all could stem from anxiety.
Parents can pay attention to their child’s development and daily activities to watch for any debilitating signs of anxiety, Hanna says. For example, a child or adolescent who suffers from separation anxiety—which may show through constant thoughts about the safety of guardians—may have a low appetite or sleep problems.
“In this scenario, they may become fearful at night, unable to sleep alone, have fears of the next day at school without their guardian, or have a poor appetite along with stomach aches,” said Hanna. “All these signs can affect their development and interfere with usual daily life.”
Hanna also points out to parents and caregivers that when their child is in school, having open conversations with their teachers may provide helpful insight to how the child is behaving outside of the home. Their teachers may notice if a child is being unusually shy and not interacting or participating in class. Conversely, the teacher may not be aware of behavior that could be happening at home and by parents having clear communication with teachers, a better understanding can help support the child.
Yes. Anxiety is a part of daily life. When someone is feeling anxiety or stress in a non-clinical sense, they are experiencing something innately human. This could be when someone is completing tasks and has mild stress that comes in small doses like before giving a presentation or taking an exam.
“It’s what can keep us out of trouble when we are preparing to cross the street, or when we go swimming in open waters such as lakes,” said Hanna. “Younger children may have developmentally appropriate fears that fade with increasing maturity, such as fears of the dark or thunderstorms.”
If anxiety is persistent and impairing, and even more so when it affects many areas a child’s life—social interactions, school, family life—this is an indication that children need mental health professional support to help manage their anxiety.
Experts also say to watch for anxiety being uncomfortable or distressing for the child. Sometimes signs of anxiety aren’t obvious, and a child appears to be managing when they’re not.
Earlier this year, the United States Preventive Services Task Force, which is made up of nationally accredited medical experts, issued a draft of guidelines for anxiety screening in children starting as young as eight years old.
Experts explain that the newly drafted guidelines are important for parents to be aware of for several reasons. For one, it adds a larger focus on mental health and screening as part of primary care practices in a time where mental illness among youth is gradually rising, especially with the pandemic.
Other factors that can increase risk for anxiety include disruptions or difficulties with school, bullying, familial stress, challenges in peer interactions, and exposure to traumatic events.
The following article, which highlights MC3 and features MC3 psychiatrists Dr. Sheila Marcus, Dr. Maria Muzik, Dr. Joanna Quigley, and Dr. Nasuh Malas, was originally published in the Medicine at Michigan magazine’s Summer 2022 edition.
Katie Whitney | SUMMER 2022
“People are calling me, saying, ‘I and my child have been in the ER for a couple of days now, waiting for a bed. My child is suicidal. We can’t go home … and I’m terrified. What do I do? How can you help?’” says Donna Martin, M.D., Ph.D., chair of pediatrics, the Ravitz Foundation Endowed Professor of Pediatrics and Communicable Diseases, and professor of human genetics.
“And that’s just wrong.”
The situation is severe. But it is not new.
“We were shouting from the rooftops, saying we are in crisis,” says Emily Fredericks, Ph.D., professor of pediatrics and director of the pediatric psychology division at Michigan Medicine. “There are not enough mental health providers to meet needs of children in our state. We knew we were in a dire situation.
“The pandemic has exacerbated that. Infinitely.”
“I’ve said it so often it sounds trite,” says Gregory Dalack, M.D., the Daniel E. Offutt, III Professor of Psychiatry and chair of the department. “All these needs were there. The pandemic has really just squeezed the vise on the system.”
That squeeze prompted an unprecedented event last fall when the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in child and adolescent mental health.
“We have thousands of patients waiting to get access to child psychiatric ambulatory services within our health system and in the community,” says Nasuh Malas, M.D., associate professor of psychiatry and of pediatrics and service chief for child psychiatry at C.S. Mott Children’s Hospital. Malas and his colleagues published a study in Clinical Pediatrics in January showing an 18% rise in initial psychiatry consults at Mott from July 2020 to January 2021 compared with the 2019-2020 time period. This is a four-fold increase in mental health consultation demand compared with the rate of increase from previous years.
And it’s not just the sheer volume of demand that has increased, but also the acuity of distress for individual patients. A Michigan Medicine study published in Clinical Child Psychology and Psychiatry in March shows that pediatric patients receiving psychiatry and/or psychology services during the pandemic were more likely to require restraints and antipsychotics than those treated just before the pandemic. “We used to see middle-of-the-road severity,” says Fredericks. “Now every patient worries me.”
We have a tsunami of need across the country, and we have little more than sandbags to meet it.
As with natural disasters, there are heroes of this crisis — both visionaries who have seen this coming and have spent many years preparing, as well as those who have been called to action at this sharp pain point. But according to the myriad mental health experts interviewed for this article, what is needed even more than individual heroes is broad systemic change.
Below are seven actions that we in health care and as a country can take to help alleviate this crisis. Most of these are already underway at Michigan Medicine — at C.S. Mott Children’s Hospital, the Nyman Family Unit for Child & Adolescent Mental Health & Wellness, the Eisenberg Family Depression Center, and the many clinics that address children’s mental health.
1. Train More Providers
“The number of child psychiatrists has always been tiny, miniscule — never anywhere close to a reasonable number for the population,” says Laura Hirshbein, M.D., Ph.D., professor of psychiatry, who is also a historian currently writing a couple of books on the history of children’s mental health. In Michigan, only one county (Washtenaw) has an adequate number of child and perinatal psychiatrists.
Historically, “child psychiatrists were pretty poorly paid among medical specialties,” says Sheila Marcus, M.D., professor of psychiatry. “And at the end of five years of training following medical school, these early-career physicians had difficulty with student loans.” The Michigan Department of Health & Human Services now has a loan repayment program for mental health care providers who spend two years working at a non-profit health clinic in health profession shortage areas or in child and adolescent psychiatry hospital-based settings.
“We are training more pediatric psychologists,” says Fredericks. “[But] there is more interest than there are spots available. On a national level, there is advocacy going on to increase federal funding for training child and adolescent psychologists.” However, we are still far from where we need to be. “As a health system, we need more investment in psychologists,” says Martin. “We could easily have four times as many psychologists as we do right now, and still not have enough.”
“What we do have now that we didn’t used to have is that pediatricians are taking on the role of becoming primary mental health providers,” says Hirshbein. Most prescribing of psychiatric medications for kids is done by primary care physicians. “Families like to be treated in primary care because they have comfort with their doctor and because of the issues around stigma,” says Marcus. “The question is, ‘How can we spread out expertise so that people know what to do [when families come to them with mental health concerns]?’” says Hirshbein.
One answer is the Michigan Child Collaborative Care Program (MC3). Marcus founded the program ten years ago, when she saw how difficult it was for primary care physicians to meet the growing demand for psychiatric care. MC3 partners with the Michigan Department of Health & Human Services to support PCPs who are responding to mental health crises.
When a primary care provider initiates a consult with MC3, a behavioral health consultant triages the request, responding to questions within the scope of their expertise and forwarding appropriate cases to a psychiatrist at Michigan Medicine for same-day phone consultation. In many cases, the behavioral health consultant will also identify local resources for the patient.
MC3 has been able to leverage the psychiatric expertise of a handful of psychiatrists at Michigan Medicine to meet the needs of children and women across the state. As of March 2022, MC3 has enrolled 3,100 providers, responded to 38,000 service requests, and helped 16,000 patients.
The MC3 Program is also one of several in the country that has a thriving perinatal consultation program, providing consults to primary care physicians caring for women during pregnancy and postpartum. “When mothers with depression and trauma are identified early, it makes it possible for consultants to guide them toward infant mental health specialists who help foster healthy, secure attachment relationships with their babies,” says Marcus. “This early bonding helps ensure a healthy developmental trajectory for infants from the start.”
MC3 has also given primary care providers continuing education in mental health care, through its educational modules on topics like eating disorders, ADHD, and other mental health issues. Training these providers to become better mental health caregivers is one way that MC3 has helped to increase the number of providers who can meet the demands of the crisis.
2. Innovate to Increase Access
Mental health concerns are common. About 1 in 5 children has a diagnosable mental health condition, but only half of them get proper care. Though holistic medicine and whole-person care are widely accepted and generally touted as important, mental health care is too often siloed in specialty practices that remain inaccessible for many families.
“We need to make sure mental health care is accessible to everybody in the way that physical health care is accessible,” says Joanna Quigley, M.D., associate professor of psychiatry and of pediatrics, as well as associate medical director of child and adolescent ambulatory psychiatry services. “It should be just as easy as accessing a primary care provider for a well-child check.”
This is an area where the broader health care community could use large health systems like Michigan Medicine as a role model. At C.S. Mott Children’s Hospital, psychology and psychiatry services are fully integrated into children’s medical care. “Having psychologists integrated where kids are getting care provides better care and better access,” says Kristin Kullgren, Ph.D., associate professor of pediatrics.
“We’re thinking about how we can be more thoughtful about integrating care, embedding mental health professionals in medical settings. We’re working with medical providers to ensure we’re screening early and providing preventive services,” says Malas, who directs the psychiatric consult service at Mott.
Another innovation that has improved access to mental health care is telehealth. It’s hard to believe that just two years ago, telehealth was relatively rare. “Pre-pandemic, I did a total of one virtual visit with patients,” says Kullgren. But now she is a big proponent of telehealth, especially for children’s mental health. “For me and my patients, there are a lot of positives to virtual care. Access is huge for kids. They can log on from home, from school, the McDonald’s parking lot, wherever they happen to be, and I can give them care. Whereas before, what used to take half a day or a day to come to the appointment, now takes just the appointment time.”
In addition to integrating mental health care with medical care and continuing to expand access to mental health care via telehealth, we also need to think of innovative ways to relieve the current pressure on psychiatric emergency services.
Right now, psychiatric beds for children are at 95% capacity at the Nyman Family Unit, says Malas. “At any given time, we may have 6 to 8 kids in our health system waiting on a psychiatric bed.” Some may wait for several days.
The answer is not necessarily more beds. “We need to get care to patients locally and early in way that is feasible, sustainable, and natural, rather than having people coming to ER in the middle of the night in crisis,” says Malas. He also recommends expanding mental health services “so it’s not just an outpatient/inpatient model.” He says we need urgent care centers that are equipped to handle mental health issues, respite centers for adolescents who need a cooling-off period, and partial hospitalization programs.
Malas and Quigley are part of a group that is developing a partial hospitalization program for children and adolescents. A program like this could provide intermediate-level psychiatric care, similar to the partial hospitalization program that already exists for adults.
“We have to shift our framework to not think about mental health care as something that only happens at a psychiatric clinic,” says Quigley. “We need to integrate this care into all aspects of the health care delivery process.”
3. Improve Insurance Coverage
For many families, having access to mental health care is almost synonymous with having insurance coverage. But from an insurance standpoint, mental and physical health are not treated equally. “Insurance companies have turned toward very aggressively managing mental health care to make providers show that someone really needs it, in a way that they don’t with other illness,” says Hirshbein.
“From a purely insurance-based perspective, we need federal regulatory changes,” says Jack Kaufman, Ph.D., an associate professor of physical medicine and rehabilitation who conducts neuropsychological testing for children, which, like all other mental health services, has seen an increase in demand. “We need to not have insurance companies telling us how many units of something they’re going to give us to solve it before we even [have a diagnosis].”
Kaufman also says we need to make sure the same services are reimbursed by insurance at the same rate — regardless of who provides the service. For example, she says a psychotherapy session might get reimbursed at a higher rate for a physician than a psychologist, even though conducting that kind of session does not require a medical degree. “There are services that I, as a psychologist, can’t do that cost more, and that makes sense. But the service should be charged the same, if it’s the same service.”
Making this change to insurance reimbursement could incentivize the hiring of a broader range of mental health care providers to meet the demands for psychological services.
We also need to make it easier for mental health care providers in the community to be covered by insurance. One reason that large health systems, like Michigan Medicine, have such long waitlists is because they are often the only recourse for families who cannot afford to pay out-of-pocket for mental health care.
4. Learn More about Kids’ Brains
“The period of preadolescence through adolescence into early adulthood is really when mental health problems emerge,” says Mary Heitzeg, Ph.D., professor of psychiatry. “It’s also when the brain is going through critical developmental processes.”
She and Chandra Sripada, M.D., Ph.D., associate professor of psychiatry, are principal investigators in the Adolescent Brain Cognitive Development Study (ABCD). The groundbreaking nationwide study includes 21 sites where data is being collected on 11,800 youth (720 of them are enrolled at Michigan Medicine). Before this study began six years ago, a really impressive sample size for a study like this would have been 100, says Heitzeg.
Every year, each of the enrolled youth and one of their parents undergoes an eight-hour assessment. That includes neurocognitive tasks as well as a sizable set of questionnaires that glean data on everything from sleep quality and substance use to screen time and extracurricular activities. At baseline, and every other year afterwards, the assessment includes fMRI to record brain changes. Researchers also collect data at the midpoint of each year.
But how can simply having all of this data improve children’s mental health?
That’s where another technological advancement comes in: data sharing. Data from the study is accessible to researchers around the world, and some 400 studies based on ABCD have been published so far, says Sripada. The richness of the data set allows for an astounding array of interpretations that could have profound implications for kids.
“One of the things that ABCD has helped us to definitively establish is that socioeconomic factors — resources of the household, income relative to needs, neighborhood disadvantage, and parental education — have big effects on kids’ brains, in the brain structure, in connectivity patterns, and in the ways the brain responds to tasks,” says Sripada. “This might have some policy implications.”
Heitzeg points out that the longitudinal nature of the study will also allow researchers to see the outcomes associated with these brain changes. “Are they more at risk for mental health problems, doing worse in school, etc.?”
Heitzeg says another richness of the study is that “we have all this other info. For example, organized sports. We can, in theory, have a group of kids with the same socioeconomic status and same brain changes, but they’re in sports and another group is not. We can see how a potential protective factor like [sports] may moderate the outcome.”
“The last piece of the puzzle is the influence of macro-environmental events, for example, COVID-19, or the profound and long-term impact of major wartime disaster, like that in Ukraine,” says Robert Zucker, Ph.D., active emeritus professor of psychiatry and psychology, director emeritus of the Michigan Medicine Addiction Center, and one of the original principal investigators on the ABCD study.
Zucker has had a career-long interest in the causes and treatment of mental health problems and conducted a study on the origins of behavioral problems and substance abuse in children to examine these questions. The study ran for 31 years, beginning in 1985 with children ages 3-5, the earliest developmental age that had ever been studied in this way. It also included data on those children’s parents, and Zucker says it has been the longest running study of the family interactional matrix and how it might contribute to the development of these problems or protect against it.
Zucker stresses the importance of understanding that the effects of major historical events on the health of a generation are probably an interaction with the mental health adaptation and the social resources of the youth experiencing those events. ABCD investigators have understood this, too. When the pandemic began, he says, ABCD researchers pivoted quickly to include questions in their assessments about the effects of COVID-19 on families. That study is already tracking those effects over time, and early results show such interactions.
“Most mental health problems and concerns are long-term and chronic,” says Zucker. “They remit. But a cure — a complete cure — is relatively rare. The solution to that from a public health standpoint is to prevent. The detailed knowledge obtained by ABCD has the potential to identify what the targets need to be for this long-term prevention.”
5. Prevent Mental Illness
What is the ideal age to begin helping kids in order to promote mental health and prevent mental illness? At Zero To Thrive, the answer is before birth.
Housed within the psychiatry department, Zero to Thrive delivers mental health services to individuals and families from conception through early childhood.
“The science is clear: brain development in the earliest years lays a critical foundation for later well-being, and intervention to promote early relational health has demonstrated a strong return on investment,” says Maria Muzik, M.D., M.Sc., co-director of Zero to Thrive and associate professor of psychiatry and of obstetrics and gynecology. “Effective programs need to address critical mental health needs not only through access to psychiatric care, but also by reducing the social isolation that so many families experience, supporting parents in meeting their own and their child’s emotional needs, and connecting families to resources in the community to meet the full range of family needs.”
Zero to Thrive teaches the importance of early relational health and what it looks like to build a responsive relationship between a caregiver and an infant. When caregivers are positive and responsive, a baby’s brain gets the stimulation needed to form the neural pathways to build resilience and thrive. Trainees at the Medical School work in both a perinatal clinic that serves pregnant and postpartum people, and in the Infant and Early Childhood Clinic that serves families from birth through age 6 using cutting-edge video-observation and feedback technology to support and nurture family strengths.
“While our clinic-based services are critical, if we wait for families to reach us in psychiatry, we will have only reached the tip of the iceberg,” says Katherine Rosenblum, Ph.D., co-director of Zero to Thrive and professor of psychiatry, of pediatrics, and of obstetrics and gynecology. “That is why we place a great deal of emphasis on partnering with community providers, offering training to multidisciplinary providers in perinatal and early childhood mental health, and thereby reaching families where they already are — from pediatric primary care, to early care and education, to other community-based programs.”
A key part of Zero To Thrive is a series of Strong Roots programs that help kids by building resilience in families, especially those who have been exposed to adversity such as trauma, economic oppression, or inequity. Studies of these programs have demonstrated positive impacts for both parents and children, including improved early relationships, changes in parental brain circuitry that are associated with reduced parenting stress, increased social connection with other parents, and increased utilization of community services. There are programs for moms (“Mom Power”), dads (“Fraternity of Fathers”), and military families, as well as a program for early childhood educators who work with infants and children in preschools and nurseries. Zero To Thrive has trained professionals who are rolling out these programs in community-based organizations all over the country. Zero To Thrive also conducts research, education initiatives, and a clinical enterprise to help pregnant and postpartum people with mental health issues.
“Schools, primary care providers, and local community resources need to find ways to integrate mental health and well-being in everything they do,” says Malas. “We need to see mental health as a shared responsibility of all professionals who interface with children and families.”
Another program started at Michigan Medicine that takes that integrated mental health model to heart is TRAILS (Transforming Research into Action to Improve the Lives of Students). TRAILS equips school staff with the training, resources, and clinical tools necessary to implement its three tiers of programming: 1) Social and emotional learning to promote resiliency and build students’ self-regulation skills, and self-care strategies for staff to counter stress and burnout; 2) Early intervention for students with mental health concerns; and 3) suicide risk management and care coordination for students in crisis.
Studies show that students who receive the cognitive behavioral therapy and mindfulness training offered by TRAILS demonstrate a 16.9% decrease in symptoms of depression and/or anxiety, as well as an increased use of self-regulation and coping skills.
The Eisenberg Family Depression Center also offers a Peer-to-Peer program that began in 2009. The program educates middle and high school students about depression and depressive illnesses and helps them find creative ways to convey this knowledge to their peers. The program received the American Psychiatric Association’s Gold Award for academic programs in 2019.
6. Help the Helpers
Attending to the needs of mental health care providers is a key component of protecting children’s mental health.
A small change that could help these providers is to increase understanding of the many mental health specializations. “Would you send someone with a tummy ache to a dermatologist?” Kaufman asks. She often receives inappropriate referrals because referring providers are not aware of the full range of subspecialties within psychology and where to go for a given concern. For example, the neuropsychological testing that Kaufman does targets primarily cognitive concerns and diagnostics as opposed to behavioral or mood treatment, but someone might assume that she handles patients with those latter concerns because she is a psychologist. It’s not just that it’s frustrating to get an inappropriate referral, but it is an inefficiency in the system of mental health care that, if corrected, could free up specialized providers to offer the right care to the right patient at the right time.
A bigger challenge is offering better support to providers. “The mental health of the mental health providers is really low right now,” says Kaufman. “We’re the people who listen to everyone in crisis.”
At the beginning of the pandemic, she and other mental health care providers at Michigan Medicine banded together to support frontline health care workers. There were 200 volunteers who provided in-person and virtual counseling to their Michigan Medicine colleagues who were seeing the worst of the pandemic. They also helped to educate them about the way trauma affects mental health and what they might expect to experience over time.
Now those volunteers are the ones experiencing an enormous burden, as the demand for mental health care far outstrips the supply of providers. Kaufman believes a meaningful first step towards helping mental health care providers would be to honestly acknowledge the ways they are suffering. “Appreciation is [best] shown by listening and hearing and being engaged in what’s happening.”
7. Change the Conversation
In the late 1960s, Congress commissioned a study that resulted in a report called Crisis in Child Mental Health. Hirshbein says, “It called out things like systemic racism, [showing] there’s no way poor black kids can survive and thrive if living in these conditions. What’s striking about this report is there’s nothing in it about psychiatric diagnoses or medication.
“Child psychiatrists at the time were mostly psychoanalytical, but they were also activists,” says Hirshbein. “They wanted government to do things to help kids. They were about big social changes.” The Crisis in Child Mental Health report was initiated under President Johnson’s administration, “but it landed on President Nixon’s desk, where it promptly died.” There were no big social changes coming.
Then, in the 1990s and 2000s, psychiatric medications for children became more accessible and commercialized, says Hirshbein. “The idea of diagnosing, treating, and focusing on mental illness was really a shift for child psychiatry. Yet the numbers of kids who are meeting criteria for mental illness are not going down. Something is happening, and we’re going in the wrong direction.”
Hirshbein believes it could be helpful to shift the conversation back to the question guiding the 500 experts who worked on the Crisis in Child Mental Health report: “What does it mean to raise a child to be healthy?”
One answer to that question involves helping kids learn basic social skills and rules of civility, assets Martin sees as casualties of the pandemic. “The skills we need to function as a society are under threat now,” she says. “We’ve lost the social fabric of our community interactions, and Zoom is not a replacement for in-person communication.”
Martin believes the isolation caused by the pandemic is especially fraught for children, who are just learning how to be social. She also worries about the increasingly uncivil tone of online discourse. “How do we course correct in a society where being vitriolic or accusatory or, frankly, abusive becomes the norm?
“If you’re a child growing up in this environment, I worry about what you’re going to look like 10 years from now. It’s really scary. How do we create those meaningful interactions for families, individuals, and communities?”
A positive of the pandemic has been a shift in public conversations about mental health. “We’ve come a long way in addressing the problem of stigma in mental health,” says Martin.
“I think it’s great that we’ve declared this mental health crisis and that it’s been acknowledged by several professional organizations and in the State of the Union address,” says Quigley. “But this was brewing long before COVID-19, and I hope it continues to sustain people’s attention and investment, because this is not going anywhere. There will be a generation of kids impacted by COVID-19 who will have needs ongoing. I think about my 3.5-year-old … COVID-19 is the life she remembers. The repercussions will be felt for a long time.”
Dr. Joanna Quigley, a consulting psychiatrist for MC3, co-authored a policy statement on the recommended terminology for medically accurate, person-first, non-stigmatizing substance use disorder terminology.
The American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention released a policy statement on the recommended terminology for substance use disorders.
Co-Authored by Joanna Quigley, M.D., the purpose of this statement is to provide medically accurate, person-first, and non-stigmatizing terminology for substance use disorders in the specific context of infants, children, adolescents, young adults, and families.
“This policy statement is needed, and being mindful of terminology is needed for many reasons. One reason is to remind providers that it is important to speak in clinically accurate ways, that reflect current knowledge/scientific understanding of substance use disorders.”
“It is also important for the families we work with, and the patients we take care of. There is already so much shame and stigma for folks around mental health concerns, but even more so for substance use concerns in themselves, or in their families. Being mindful of language allows us to engage with our patients and communities in a more understanding, empathic, and empowering way. It helps both the patient, their family, and their providers to feel that this is a challenge that can be addressed with evidence-based interventions, that there is hope, and that it does not define the value of the person.” – Dr. Joanna Quigley
The policy statement is the first of its kind to be used among pediatricians, media, policymakers, and government agencies and in its own peer-reviewed publications. It provides 3 specific recommendations regarding medically accurate diagnostic terminology, person-first language, and terminology for use in the discussion of the treatment of SUDs. The policy statement also includes helpful examples of problematic language, and recommended language/terms along with an explanation for each.
The following article and podcast were originally published on the U-M Public Engagement & Impact website.
Mental health care isn’t only provided in psychiatrists offices. It often occurs in family doctors’ or primary care providers’ offices, especially when the care is for children and young adults. Those providers, however, aren’t always equipped with the resources needed to address mental health concerns of their patients. That’s where the Michigan Child Collaborative Care Program, or MC3, comes in.
MC3 is a statewide program connecting primary care providers with psychiatrists and behavioral specialists for consultations and training to support their ability to provide mental health care in their clinics. Sheila Marcus, MD, heads the pediatric component of MC3 and is a professor of psychiatry at Michigan Medicine. Marcus joined Michigan Minds to talk about the importance of providing pediatric and perinatal mental health support across the state of Michigan and explain how MC3 is working to do just that.
Listen to the podcast on Spotify
MC3 provides same-day phone consultations to offer telepsychiatry sessions with patients and to bring education and resources to providers who are trying to find psychotherapeutic resources for children and mothers.
“The program is currently available in every county in the state of Michigan and has grown from a very small program in a few counties to covering all of the lower and then all of the upper peninsula. The program is designed really to leverage what has become an extremely, extremely scarce resource: both the child and adolescent and perinatal psychiatrists. And to try to get our expertise into the communities in Michigan that need them.”
Marcus addresses why this support for providers is so necessary, saying that is a “tsunami of need out there, particularly in children’s and in perinatal mental health.” The program began in 2012, but the COVID-19 pandemic brought the problem to the forefront.
“During the pandemic, what we’ve discovered is that rates of depression and anxiety in all of these populations has skyrocketed, suicide is increasingly problematic for both kids and for women. Our emergency rooms are bursting at the seams. There are not enough beds for the population of people that need them. The lines in the mental health service programs are longer than have ever been in my 40 years in this field,” she says.
“Deaths due to guns are now the leading cause of death in children and adolescents which is absolutely shocking. And there’s an absolute acute, really catastrophic shortage in almost every county in the state of Michigan. So, PCPs are increasingly finding that they’re spending more and more of their time doing this and they simply can’t keep up. They absolutely need additional support.”
Any prescribing clinician in Michigan is eligible to enroll or MC3. Once they are enrolled, they are immediately eligible to call. Since many individuals are comfortable with their known clinician, this service provides a unique opportunity for the physician to call for support rather than send them elsewhere, Marcus explains.
She emphasizes that this is an important time to talk about mental health overall as well. Not just during Mental Health Awareness Month, but every day. Increased public awareness will help reduce stigma around mental health conditions, and Marcus says it is promising that it is being talked about more often.
“Mental health conditions are extraordinarily common, and right now, there is a critical shortage of individuals to support people who are caring for individuals with mental health conditions. I think the state of Michigan is trying very hard to get expertise into the hands of people who need it to try to meet some of this demand,” Marcus says.
“But I think the other important thing is for people to know that mental health conditions are treatable and it is important to seek treatment for these conditions, and to try to think very creatively as a state, as academic clinicians, as to how do we best match treatment resources to individuals who need them and try to get resources in a more equal way into the hands of people who need them.”
This Q&A is an excerpt from the Second Wave Michigan article by Estelle Slootmaker titled “Special report: COVID-19’s silver linings for mental health care in Michigan”
This interview has been edited for length and clarity.
Q: Why is it important that we focus mental health efforts on children and teens?
A: We are beginning to discover what was a substantial problem in the state of Michigan before the pandemic has become a tsunami of need during and following the pandemic. About 20% of children and adolescents will have some sort of mental health issue, depression, anxiety, ADHD, autism, trauma, OCD, and a whole host of issues. That has increased during the pandemic. The data now is something like 40% of adolescents report mood and anxiety symptoms during and following the pandemic.
In places where there exist child-mental-health-trained or child psychiatrists, the wait times are anywhere between four and six months. The vast majority of the counties in the state of Michigan don’t have any trained children’s psychiatrists. So there’s no wait time because there’s no line to wait in. In those cases, generally, children are being cared for by pediatricians, family medicine physicians, or nurse practitioners.
Q: What kinds of mental health challenges does MC3 help pregnant women and new mothers overcome?
A: The most common complication of pregnancy is postpartum or pregnancy-related depression. The postpartum period is often a time when women who have bipolar illness have their first episodes. The other big issue in pregnancy and postpartum is trauma. So many women are victimized during their pregnancies. In the case of women with domestic violence histories, there often are uses of substances including marijuana and alcohol, sometimes opiates.
We’re very mindful that when we’re caring for pregnant moms, we also have to care for the babies, even during the pregnancy. If we have a victimized, traumatized, substance-abusing, depressed mom, simply treating the mom’s disorders will be insufficient. You have to make sure that mom and baby get into infant mental health services to give mom the skills that she needs to form a healthy attachment relationship to the infant. We sometimes call this ‘the dance of early childhood,’ moms looking at babies, babies looking back at moms, and falling in love with one another.
Q: What role can primary care providers play in meeting the mental health needs of these women and their infants?
A: Many obstetricians are doing a screening for depression, anxiety, and trauma during pregnancy. They’re more likely than anybody to pick up on signs and symptoms of some of these disorders. They may have followed the mom in other pregnancies and have a sense of whether there have been other issues. In family medicine [practices], doctors are following moms during pregnancy and postpartum as well as their children. They’re really connected to the family, sometimes for many generations.
Q: How is MC3 engaging these PCPs?
A: Our role is to support and scaffold the primary care docs in caring for the children that are already in their panels for primary care. After they’ve called us once or twice, they realize that we’re here to support them and here to validate that the work that they’re doing is incredibly difficult — not chastising them for not being able to do things that they weren’t trained to do.
We also do “brown bags,” clinical case consultations, where a group gets together and presents a case or two to discuss cases over lunch. We have a variety of recorded modules available to practitioners on a whole host of topics like depression, anxiety, eating disorders, LGBTQ issues, and suicide. We’ve begun a specific suicide prevention and safety planning [module], which we’re delivering to 60 or 70 practitioners several times a year. Since COVID, there are now billing codes that allow them to bill for consultations, report writing, tests, or multidisciplinary meetings that happened on the same day as a [patient] visit.
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