AAP Issues Report on Barriers to Mental Health Treatment for Young Children

In a report published in Pediatrics, the American Academy of Pediatrics (AAP) discussed several barriers to care for young children with mental health problems. The authors suggested that prompt access to treatment and more complete training for pediatricians could help remove some of these barriers.

Around 8% to 10% of children younger than age 5 experience mental health problems that impair their emotional, behavioral, or social functioning. These issues are often persistent, putting children at risk of later mental and physical disorders. The report acknowledges the importance of prevention programs targeted at high-risk children, but its main focus is on the treatment of clinical problems that have already been identified.

The first-line treatment for children with mental health concerns is family-focused psychotherapy, which can remain effective for years after the treatment ends, unlike pharmacologic treatments. These interventions can help regulate the emotions and behavior of children with issues like anxiety or attention-deficit/hyperactivity disorder (ADHD), in part by providing new approaches and tools for parents.

Psychotherapies for infants and toddlers are based on attachment therapy, and aim to improve the parent-child relationship by helping parents be more sensitive to their child’s emotional needs. For preschoolers with ADHD or behavior disorders, there is evidence supporting the use of parental management training models to reduce disruptive behavior symptoms. Cognitive behavioral therapy and parent-child psychotherapy have been shown to reduce anxiety symptoms for children who have undergone trauma. The study authors noted that although studies of these interventions have shown positive effects, they are not a good fit for all families.

The report briefly discusses the increasing use of psychopharmacologic treatments, which have not been studied extensively in young children. Due to their potential risks and the lack of evidence supporting these medications, the AAP instead favors the use of nonpharmacological, evidence-based treatments. However, less than 50% of young children with emotional, behavioral, or relationship disturbances receive any treatment due to a number of barriers limiting their access to care.

First, many psychiatric residents and other mental health professionals enter the primary care setting with very limited experience in studying early childhood mental health. As such, there is a shortage of child psychiatrists and pediatric specialists with the training necessary to meet the unique needs of young children, especially in regions not near academic centers.

The report names the medical payment system as another barrier to access, because it reimburses primarily for brief, medication-focused visits. The relationship-focused therapies recommended for young children are generally not recognized by the medical billing and coding system.

Finally, stigma is a pervasive factor that impedes access to mental health treatments for young children. Parents may be discouraged from seeking treatment for their children due to their own perceived stigma or experiences with mental health, or the worry that taking their child to a mental health specialist could increase their risk of referral to child protection services. Providers may be hesitant to refer young children to specialists out of concern that the child will be “labeled.”

The AAP has developed several strategies to address these barriers. It created the “HELP” mnemonic to remind clinicians of the importance of “offering hope, demonstrating empathy, demonstrating loyalty, using the language the family uses about the concerns, and partnering with the family to develop a clearly stated plan, with the parents’ permission.”

The report also recommends greater collaboration between primary care pediatricians and specially-trained mental health clinicians. Because clinical mental health problems can commonly co-exist with other developmental delays, a comprehensive treatment plan for young children should address mental health along with any other comorbid conditions.

To effectively promote well-being in these young children, the authors summarize, pediatricians must “promote the use of safe and effective treatments and recognize the limitations of psychopharmacologic interventions.”