Much of the discussion about behavioral health concerns during the pandemic has been focused on adults, even though children appear to be experiencing more mental health issues amid the crisis. A team from Seattle Children's—Ginger Hines, executive director; Sheryl Morelli, medical director and CMO; and Larry Wissow, chair of pediatric psychology and behavioral medicine—sit down with Radio Advisory's Rachel Woods to talk about the behavioral health issues children are facing in the wake of the Covid-19 epidemic.

Read a lightly edited excerpt from the interview below and download the episode to hear the full conversation.

Rachel Woods: I want to start by reflecting on the past. I know that Seattle Children's has been focused on pediatric behavioral health for some time now. Give me a sense of what the state of pediatric behavioral health was before the epidemic. When did you realize this was a problem that you needed to invest in?

Larry Wissow: One way of looking at it is that we knew ahead of time that it would be a problem. The kids who are junior high and high school students now are the children of the great recession from 2008. They lived through the opioid crisis, it was pretty clear from the get-go that this was going to be a really big second hit and we'd have to be ready to see a big surge in demand.

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Woods: Yeah, let's talk about what happened when Covid-19 hit. We talked about the kind of effects of stress, isolation, just the trauma of living through a global crisis when it comes to adults. We've talked about that on the podcast before, but how has it specifically affected kids?

Sheryl Morelli: We've definitely seen increased rates in depression, anxiety. One that surprised me was a pretty big increase in eating disorders, and then a very significant increase in suicidal ideation. We are seeing this across all health care sectors. So in primary care, our EDs, our inpatient units, our ICUs.

Woods: So you're primed that this problem is going to be big, it's something that we were tracking before the epidemic. Certainly the numbers have not gotten better, but I guess my question for Ginger is, when did you decide that you wanted to make a big investment here? Were there specific metrics? Was there a specific moment that you knew, we need to put our money where our mouth is?

Ginger Hines: Well, one advantage of working in a clinically integrated network and having arrangements with health plans is that we get a lot of claims data. So even before Covid-19, we were seeing trends in growth for children and behavioral health crises and services growing.

There's obvious clinical indications and reasons to invest that Larry and Sheryl can speak to, but from a financial perspective, over several years of claims data from these contracts, we found that by in large children with behavioral health comorbidities were often upwards of three times more costly in terms of their utilization of other services. That's not dissimilar to what is found in the adult population as well.

Woods: Yeah, I do appreciate you bringing up cost but I'm always super wary of talking about cost in the health care space because it can mean different things for different organizations who are in different business models.

If you have risk-based arrangements, it makes sense for you to try to reduce total cost, but not every hospital, not every health system has arrangements that incentivize that sort of work. Do you have advice when it comes to the financial picture, for other leaders who might be thinking, I know I need to invest in behavioral health but honestly, it's going to be a loss leader?

Hines: From a population health perspective, and Larry and Sheryl can chime in on this too, I think our goal is to put ourselves out of business.

We don't want kids in the hospital, we don't want them seeking treatment, and it's working. So we're early in on this but our goal is to break even.

Wissow: I think there are other incentives when you look at it also from the perspective of being in a major referral hospital. I think you've probably seen the national data that shows that the proportion of children coming to EDs with mental health problems have gone way up.

Some of that's because the overall volume has gone down somewhat, but one of the huge drivers for us frankly, are the complaints from our colleagues in the ED, our complaints from our colleagues in the hospitalist services, that they don't want our mental health patients crowding out their other business.

Woods: So it sounds like at Seattle Children's, you've identified the problem. Things are not good and you've established a business case, and I appreciate you being a little bit more holistic in what that business case is.

Let's talk about the actual investments that you made. I want to ask each of you to just say quickly, in your mind, what's the single most impactful thing that Seattle Children's has done when it comes to the pediatric behavioral health crisis?

Morelli: I really think our Guild Association, having the foresight to designate money to pay for behavioral health professionals to get into pediatric primary care practices has been instrumental in us starting to be able to make a dent in treating behavioral and mental health more effectively.

Woods: Ginger, what about you?

Hines: Yeah, similar—helping to support the cost for private practice, pediatricians, to embed help in their practices and to get way upstream of the problem.

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Woods: Larry, what would you say?

Wissow: I think that the biggest thing that the Covid-19 crisis has done to help us respond has actually been to make our own department work as a system. Previously, it really hasn't.

We have an inpatient unit, we have outpatient services and they almost negotiate with each other as if they're separate entities. Covid-19 has meant that we have had to come together, we've had to really think of ourselves as a system and not as just a collection of individual activities. We've had to think about how to round it out.

I think the final thing is that the thing that will ultimately be the biggest payoff I think is realizing that we've got to be truly family centered, which is a huge challenge for a child defined organization.

Woods: Part of me keeps thinking that gosh, doctors have so much on them right now, especially during this epidemic, and primary care is not excluded from that.

I know from experience in trying to get primary care physicians to shift their workflow can sometimes be like pulling teeth. Ginger, how do you actually make it easy for those primary care providers to tap into the behavioral health support that you're providing them or that you're pushing them towards?

Hines: Yeah, one of the things we recognize, there's a lot of whirlwind at a primary care practice—they're busy all day, there's not a lot of time. So we come alongside with practical support for care transformation coaching. So people who've worked in primary care, they understand, and they can come alongside and support by saying, well, how do you actually organize and get this work done?

Also, project manage that and help coach the staff along the way, and be the wind under their wings to come alongside with some real practical side by side support for them to make these changes. It's hard, it's hard to change what you're doing when you've got your clinic's busy all day from the time you open to even after you close. So we recognize, that's a key piece.

Wissow: But there's tremendous motivation for doing it. I mean, first of all, because such a large proportion of visits have a psychosocial or a mental health component.

Secondly, because it really only takes one unanswerable doorknob question of, oh yeah, by the way, he harms himself, to put a wrench in your day. So the bottom line is that there's pretty good evidence that being more psychosocially oriented in the course of your primary care visit and being able to address these kinds of things efficiently in the practice actually makes you more productive, not less.