While public awareness about the current mental health crisis among U.S. youth has increased during the pandemic, many people still lack an understanding of the challenges of accessing and delivering appropriate psychiatric care for young people.
Chief among the hurdles faced by patients and their families is access to trained child and adolescent psychiatry clinicians, due to a longstanding workforce shortage in the field.
According to a January 2021 article in Pediatrics, a 2019 study found that “thirty-six states have fewer than 10 child psychiatrists per 100,000 children, with only 3.3 child psychiatrists per 100,000 in the most extreme case.”
“People were dealing with problems like poverty, food insecurity, domestic violence, poorly resourced schools before the pandemic,” says psychiatrist Greta Spottswood, M.D., M.P.H., a Class of 2011 alum of the University of Vermont Larner
College of Medicine. “[These issues] ballooned during the pandemic, and at the same time, the workforce shrank,” she notes.
Spottswood, who joined Vermont’s Community Health Centers (CHC) in 2017, started her career in Boston, where she completed a general psychiatry residency and fellowship in child and adolescent psychiatry at the Cambridge Health Alliance—a
health system widely recognized for its innovative approaches and dedication to providing equity and excellence. Equity and population health has long been a priority for Spottswood. As a medical student, she both worked in the UVM Children’s
Hospital’s New American Clinic and co-led a New Hampshire/Vermont Schweitzer Fellows project focused on developing curriculum to enhance patient-centered care for LGBTQ patients of all ages.
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Establishing a system to get mental health care to the children who need it
While in Boston, Spottswood recognized that there would never be enough child/adolescent psychiatrists to meet patients’ needs working within standard systems. This led her to seek ways for child psychiatrists to extend their expertise to help more children, which included supporting primary care providers and models for delivering integrated care at the clinic level.
For the first couple of years after coming to CHC, Spottswood provided psychiatric care alongside primary care providers in the clinic, which she says she loved and where she learned a lot. She admits, however, “The current system underserves the patient. My wait list was six months for a follow-up appointment, and that’s not safe care.” She set out to identify where gaps existed both at her clinic and across the state and looked at how other states were addressing the issue, with a goal of finding a program that provided equitable access to primary care providers across the state. “I knew there was a big need for primary care providers working rurally,” she says.
The January 2021 Pediatrics article strongly supported the implementation of Child Psychiatry Access Programs (CPAPs) as an innovative model to help primary care pediatricians provide more robust mental health care, and concluded, “The existing data and anecdotal evidence indicate that CPAPs are an effective strategy for leveraging the existing workforce of child psychiatrists [to] help more children.”
Vermont was one of only a handful of states without a CPAP, so Spottswood helped launch an effort to get one established. She received private funding through the Vermont Community Foundation to start the process. Then she connected with the Vermont Department of Mental Health (DMH), the Division of Maternal and Child Health in Vermont’s Department of Health (DoH), UVM’s Vermont Child Health Improvement Program (VCHIP), UVM Medical Center, and designated agencies like Howard Center and Northeast Kingdom Human Services to gather recommendations for Vermont’s CPAP. She also checked in with patients and families, reviewed the existing literature, and learned from what other states are providing to confirm that such a program would be helpful.
She worked with Vermont DMH, DoH, and VCHIP to help Vermont obtain a Health Resources and Services Administration (HRSA) Pediatric Mental Health Access Care grant, which was offered to states trying to start or expand child psychiatry services to improve accessibility.
Vermont received the HRSA grant—some to fund the CPAP and some for other initiatives—and DMH announced the launch of VTCPAP in June 2022. The program, for which any Vermont primary care provider (PCP) serving children and adolescents 21 and under is eligible to register free of charge, provides telephone consultation service to assist PCPs with diagnosis, medication management, psychotherapy recommendations, and community-based referrals.
The timing of the program has been critical, given the rise in child and adolescent mental health issues since the onset of the COVID-19 pandemic.
“The uphill battle around social determinants of health for families during the pandemic became even more challenging,” Spottswood says, citing the example of the increase in domestic violence. “Kids couldn’t go to school and had to stay home. Things continue to be hard at school, and there is still illness and increased absences. We’ve learned from schools that many kids came back [to school] with signs and symptoms of trauma.”