Child and adolescent mental health services in high demand; experts label it a crisis

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association jointly declared a national state of emergency in children's mental health. There were challenges before the pandemic, which has only made things even more challenging. So today I'm talking about this with Dr. Ron Saletsky. He's a child psychologist at Upstate, where he's a professor of psychiatry and behavioral sciences, and a professor of pediatrics. Welcome to The Informed Patient, Dr. Saletsky.

Ron Saletsky, PhD: Thank you so much, Amber. I appreciate the opportunity to talk about mental health services for children and families at Upstate.

Host Amber Smith: This is such a serious topic, and it's a very real crisis for so many families. So I wanted you to tell us about the types of mental health services that are available at Upstate for children and adolescents.

Ron Saletsky, PhD: Absolutely. I just, as I began, I just want to reiterate what you said, that the mental health challenges for kids and families are greater than ever these days. Rates of depression and anxiety in children and youth that had already been steadily increasing over the last decade have been exacerbated by the pandemic and as such, the stress level for families as a whole has also risen. So this is, for lack of a better word, a bit of a crisis time for kids and families. There are absolutely outpatient services available, for emotional and behavioral problems in children here at Upstate. We typically work with kids at about pre-K age, so three and four years old, up through 18, and their families. All of the services are available at the department of psychiatry. Certainly there are mental health providers all over Upstate, and I can talk about that in a minute, but the largest group of providers is clearly at the department of psychiatry. Within the department, we offer a couple of groups of providers one are our staff at University Hospital child and adolescent psychiatry clinic. And the other is the faculty practice group. Both offer highly skilled clinicians of multiple disciplines, and certainly virtual appointments are available.

Host Amber Smith: I wondered about that because during the pandemic, I know it a lot of doctors have been offering that. Does that work, for psychiatric issues?

Ron Saletsky, PhD: Well, it's a challenge. It's a barrier between, you know, it's a relational business that we're in as mental health providers. And whenever you put something in between it can be a barrier. However, we've had a lot of experience with it over the last year, just because of the pandemic. And it is possible to offer and receive high quality services. It is more difficult with the youngest kids because keeping them on screen. I mean, they're having the same difficulties at school as well when school goes remote. So keeping kids on screen and focused can be a challenge, but that also provides an opportunity to work more closely with the parents. And it is in our view, the parent is the primary healing agents in the child's life. So it does give the opportunity to do that.

Host Amber Smith: So with the mental health services, is it family therapy? Is it group therapy? Is it one-on-one? What is it?

Ron Saletsky, PhD: We offer a whole range of services, and we choose the therapy based on a really thorough assessment of what's going on,an assessment of the problem. And then we choose from a number of possible interventions that could include individual therapy, family therapy, parent-child relational therapy, group therapy. We offer the whole range, and also parent guidance, as well. And again, the type of therapy that's chosen is based on a really thorough assessment that's done in the beginning.

Host Amber Smith: How would you advise people to access the child and adolescent mental health services at Upstate?

Ron Saletsky, PhD: So, as I said earlier, we have, um, two entry points. One is through the University Hospital child and adolescent outpatient clinic. And that phone number is (315) 464-3165, and the parent would ask for intake and then describe what's going on. The other entry point is the faculty practice group, and that number is (315) 464-3265. And again, the same questions would be asked in terms of, why you calling and you would ask for intake and then describe what was going on and see what practitioners might be available.

Host Amber Smith: Do people need to have a referral from a pediatrician?

Ron Saletsky, PhD: No, not necessarily.

Host Amber Smith: OK. If someone needs inpatient care, that's available, right?

Ron Saletsky, PhD: Inpatient care is available. Yes. There are, as you alluded to, there's a shortage of inpatient beds both locally, regionally and nationally, but we do have inpatient care in Syracuse. We have an adolescent unit, a newly developed unit over the last two years, called 7-West that's in University Hospital. It's a short-term unit. Stabilization and discharge. Basically length of stays between one to two weeks, and then, kids get discharged to appropriate level of services post hospitalization. We also have Hutchings Psychiatric Center here in Syracuse, which has a small amounts of beds at this point. They've decreased their census and the number of beds, and they can also be an option for children locally. So between the Upstate unit and Hutchings, those are our local beds.

Host Amber Smith: How long is the typical stay for children and adolescents?

Ron Saletsky, PhD: These are short-term units, especially the one at Upstate is a short-term unit. We're talking about one to two weeks, at the most, for stabilization. Every so often there's a child that may have to stay longer because of the intensity of their symptoms. But usually they limit it to one to two weeks so that there is significant turnover, so more kids can be served.

We do have an intensive adolescent program, which is really a step down from the hospital which, sometimes when you go from the hospital, which is really intensive, you need a middle ground program to continue to help you consolidate the skills that the kids are learning to not engage in such risky behavior and to develop more adaptive skills. We have these kind of special programs -- one is through the faculty practice, and one is through the clinic -- that really work with high-risk youth.

Host Amber Smith: Well, I know that it's difficult to find mental health care services across the nation right now, because everyone is in this crisis. Do you have any advice for what families can do in the meantime?

Ron Saletsky, PhD: It's really tough. I think if parents can commiserate with other parents, that can often help diffuse some of the responsibility and maybe, allow parents to get some tips in terms of working with their children. Also primary care physicians, either family docs or pediatricians can also be a source of support. Here at Upstate, we have if a family is, their child is a patient at one of our Upstate pediatric outpatient clinics, we do have some mental health services that are embedded into those clinics called integrated care. And there are some possibilities there, as well, where kids can be seen in short-term work, but again, as I said before, the main source of outpatient services is at the department of psychiatry.

Host Amber Smith: That's good to know. Now, take an emergency situation where a parent feels like they're out of options. Are they advised to come to the pediatric emergency department at Upstate? And if so, can you walk us through what would happen?

Ron Saletsky, PhD: Let me just start by saying emergency situations are incredibly scary, not only for the child, but for the parent as well. No parent wants to see their child potentially harm themselves, harm other people. So if the child or adolescent is struggling with high risk behaviors, and those include suicidal thoughts, self-harm harming others or losing touch with reality. And what I mean by that is hearing voices or seeing things that others don't see or hear. Then the safety of hospitalization may be what is needed. The inroad to hospitalization, as you said, is the emergency room. We do have two places where kids who are in psychiatric emergency would go in this community. One is CPEP, the Community Psychiatric Emergency Program at St. Joseph's Hospital. And the other is Upstate's pediatric emergency room. I can speak about Upstate. I don't work at St Joe's, but at Upstate, as I said before, if needed, we offer an eight bed short-term psychiatric unit for adolescents. OK? When there is a crisis and in an emergency, the parent would bring their child or get their child to the Upstate emergency room. At that point, the child and family would be interviewed by the consultation team or the emergency room team in order to determine current level of risk to the child's safety. That is the determining point. If the child is engaging in risky behavior and the risk is deemed high enough, then they may need the higher level of care that the hospital can provide. So if the risk is sufficiently high, inpatient hospitalization will be recommended. If there are no beds available on the local unit on 7-West or at Hutchings, or even in the regional units, the child, because of safety issues, will be admitted to Golisano Children's Hospital until a psychiatric bed opens up or until the level of risk decreases sufficiently for discharge to appropriate outpatient services. So if a child is at risk, nobody's going to just let them go back to the community. OK? There's too much risk there. There's too much on the line. A child will be admitted. It may not be to a psychiatric unit right away because there may not be openings, but they will get good care at Golisano, and maybe by the time a bed opens up the child's needs may have sufficiently decreased so that inpatient hospitalization might not be needed.

Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith talking with Dr. Ron Saletsky, a child psychologist at Upstate. We're talking about the pediatric mental health crisis and the services available for children and adolescents.

The nation, and not just Central New York, is facing a shortage of mental health care providers in general. And more severely, those who specialize in pediatrics. So let me ask you, what are the reasons for this shortage, and what do you think needs to be done to improve the situation long term?

Ron Saletsky, PhD: You know, I think the reasons are around supply and demand. Most child training for mental health clinicians, either in psychiatry, psychology, social work, nurse practitioner programs, they admit very few trainees. They are small programs to provide very, very in-depth training. Uh, we need more. We need more training programs. We need more people staying in Syracuse. We run several training programs here postgraduate. We have a psychology internship in child. We have a child psychiatry fellowship. We have a nurse practitioner fellowship. We have a social work internship. They go through these programs here at the Upstate Department of Psychiatry, and the hope is that we can keep them around so that we can grow the workforce that's needed to expand the programs that we offer.

Host Amber Smith: What do you yourself enjoy about being a child psychologist?

Ron Saletsky, PhD: Oh, wow. I can't think of anything else I could do or I'd rather do. I've been practicing as a psychologist for over 30 years. For me, I get the privilege of working with and helping people in need. Human beings are fascinating to me, as fascinating now as they were when I was in graduate school. Being able to have the honor of working with people when they are vulnerable, being allowed in to their lives, getting to know them, using whatever skills I have to help them gain more control over their lives. To me, there's nothing more gratifying. In addition, because I'm a psychologist here at Upstate, I work with professionals from other disciplines, and we found that certainly providing multidisciplinary care is the best care possible. Also in my position at Upstate, I got to teach and supervise future child mental health practitioners to hopefully add to the skilled workforce. And that's a wonderful experience, and it keeps me really sharp. The field that I'm in is one that you can continue to grow until you're done. And that's really exciting to me. And I can't think of anything else I'd rather do.

Host Amber Smith: As you're working with the incoming students, what traits do you see in a person that you can say, "well, that person's going to make a really good child psychologist." I'm trying to understand what kind of person could get into this career and do well in it.

Ron Saletsky, PhD: There are, I think, lots of variables that go into it, but I think people are I think born with certain skills, be they artistic be they scientific, be they people skills, being able to understand and be in tune with people's emotions and thinking and interactions. I think there's a certain level of that, that you need to be really good at what I do, what we do as child mental health practitioners. A love of children, a curiosity and motivation. I think curiosity is really, really important because it keeps you fresh. You, don't see everybody as the same. You view people individually when you have unique curiosity. Those kinds of traits, I think a really, really important. You can learn the therapeutic technique. That's what graduate school is about. That's what internship is about. You're really coming into it with a certain skill set and for lack of a better way of saying it, a certain instrument that you have, that's attuned to people and with continued experience and supervision, you get to hone that instrument. And, yeah, it's a complicated set of skillset, but I think part of it, you come into the world with.

Host Amber Smith: Well, thank you so much for making time for this interview.

Ron Saletsky, PhD: Of course. My pleasure.

Host Amber Smith: My guest has been child psychologist, Dr. Ron Saletsky, a professor of psychiatry and behavioral sciences, and a professor of pediatrics at Upstate. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. Find our archive of previous episodes at upstate.edu/informed. I'm your host, Amber Smith, thanking you for listening.