Children’s Hospital Colorado, where the emergency department is regularly filled with suicidal kids and leaders last spring declared a mental health state of emergency, has hired its first-ever chief of mental health.
Dr. K. Ron-Li Liaw, a child psychiatrist with a background in trauma and resiliency, will lead the hospital system as it pivots to include a focus on mental health. Liaw plans to spend the next few months creating a plan to tackle the crisis, from early intervention by pediatricians and school-based counselors, to additional hospital beds for kids in crisis.
Liaw, who previously worked at Hassenfeld Children’s Hospital at New York University Langone, wants every child to get regular mental health checkups — not just questionnaires — and has plans for Children’s Hospital Colorado to partner with school districts.
She talked to The Colorado Sun about the state of kids’ mental health, her five-year goals, and the potential for Colorado to catch up to eastern states that have invested more in treatment options.
Children’s mental health crisis has been building for a decade
Nationwide, suicide is the second-leading cause of death for young people age 10 to 24. In Colorado, it’s No. 1.
This was true even before the coronavirus pandemic and the long period of isolation, cancellations and family stress that COVID-19 caused. In the past decade, about 1 in 5 children and teens struggled with depression, anxiety or thoughts of suicide. Now, nearly half of young people have mental health issues.
“It’s been scary, actually, to watch over the last 10 years the level and the severity of mental health presentations for younger and younger kids,” Liaw said. “Pre-COVID, we were starting to see these rising rates.”
Liaw, who has three children, said the pandemic has been “as ridiculous a trauma and stressor I can think of creating in kids’ lives.” When the pandemic hit in the spring of 2020 and schools shut down in New York City, her kids expected a “two-week holiday.”
“Little did we know that those first two weeks were the next three years of their lives,” she said.
“There are so many things that I worry about as a parent and a child psychologist. When they are just trying to be kids and grow up and be with their friends, to feel good about learning …There have just been so many disruptions to our social fabric. It’s been such an isolating series of years.”
In May, when Children’s declared a state of emergency, mental health visits to the emergency department were up 90% that month compared to the same month in 2019. Kids who have just attempted suicide are regularly rushed to the hospital, and hospital rooms not set up for psychiatric care are regularly filled with children because there are no available beds at treatment centers.
From January through mid-October 2021, 70% more children came to Children’s emergency departments because of a mental health crisis compared to the same period in 2019. Children’s had more than 6,500 emergency department behavioral health visits in 2021, said the hospital in a recent news release, calling it “just the tip of the iceberg.”
How do Colorado’s resources compare to other states?
Liaw said she’s been surprised by the lack of options for children with acute mental health issues who end up in the emergency rooms of Colorado hospitals. In New York, she could seek help from several psychiatric hospitals and programs, or contact one of four governmental agencies that helped find children a treatment bed.
That’s not how it works in Colorado, where state leaders are trying to reopen children’s psychiatric beds after hundreds have closed in the past two decades.
“There has been a lot of investment in other states in youth mental health and crisis care and in-patient beds and residential beds run by city agencies as well as state agencies,” Liaw said. “When I was a child psychiatrist practicing in the ER, I had many more options. I had other in-patient units, other hospitals in the city and the region. I had a comprehensive psychiatric emergency program. I had residential programs that were run by the Department of Ed, the Office of Mental Health, and juvenile justice and child welfare. I had four layers of residential beds that I had access to. That’s really different here. Because everything is coming here — to the ERs.”
Because it’s a safety-net hospital, children with psychosis are in the emergency room alongside children with severe medical issues and kids with COVID-19.
“We can only have so much capacity,” she said. “The reason I’m here is because I see a lot of potential here.”
Children’s Hospital officials — from the data-tracking team to speciality departments — are all willing to pivot to mental health, she said. Also, Gov. Jared Polis has created a new Behavioral Health Administration and state leaders are making recommendations on how to spend $450 million in federal coronavirus aid to improve the mental health system for adults and children.
Focusing on early intervention
The key to changing course in children’s mental health is not building more hospital beds but focusing on early intervention, Liaw said.
“We are not going to be able to build our way out of this crisis,” she said. “We are not going to be able to build enough beds.
“So much of the dollars throughout the country have gone to acute care, in-patient beds, psychiatry-level beds. So much of our investments really should be spent in the community and building preventative services and early identification.”
In the past several years, Children’s Hospital Colorado has added hundreds of mental health professionals who are “embedded” in medical programs throughout the hospital, which has more than a dozen campuses including four emergency-care locations. Systemwide, there are about 300 mental health specialists including nurse practitioners, counselors, social workers, psychologists and psychiatrists. They’re stationed in the cancer unit, the breathing unit and various other hospital departments.
At a Children’s Hospital’s health pavilion where patients go for doctor’s appointments, every family gets a mental health checkup. They’re also offered assistance with food, legal advice and housing. Liaw called it the “bells-and-whistles model” for integrated mental-physical health care.
“Developmentally sensitive” mental checkups
Colorado is in the “screening stage” of combining mental and physical health care, Liaw said. She means that at the pediatrician’s office, older children and teens are likely to fill out a short questionnaire that asks about their emotions, sleeping habits or suicidal thoughts.
That’s better than nothing, but it’s not enough to solve the mental health crisis, she said.
“Hopefully practices are checking for depression. If you score high on some of these screening tools, maybe you will get flagged. Maybe they will make a referral that you will navigate as a parent trying to connect your child to these resources. What if that was a dynamic relationship that was developmentally sensitive for the kids?”
A conversation with a mental health professional is far more effective than a screening form, she said. And the conversation should change, depending on the age of the child. Just as pediatricians check for specific illnesses or give certain immunizations at the 9-year-old checkup, the 11-year-old checkup and beyond, a mental health professional in the office should ask certain “developmentally sensitive” questions during those office visits, Liaw said.
“It doesn’t necessarily need to be the same person throughout a child’s life. It’s at these critical touchpoints and moments in a child’s life where, if someone is struggling, you want to be able to get them the right support. It’s those critical conversations that somebody might not tell you on a checklist.”
Children’s has an ongoing pilot program that connects hospital psychologists with pediatricians’ offices and is working on new programs with school districts, Liaw said.
The mental health-in-chief position is on the same level as the hospital’s pediatrician-in-chief and the surgeon-in-chief. The new post, said Children’s President and CEO Jena Hausmann, “ensures that pediatric mental health is top of mind for every major decision we make.”