“The further I am into my career it gets clearer to me just how much of a full societal effort it is to support youth mental health and well-being.”
– Dr. Ron-Li Liaw
Interview with Ron-Li Liaw
A child psychiatrist based out of New York, Dr. Liaw was drawn to the new role of Mental Health In-Chief when the Children’s Hospital declared a pediatric mental health state of emergency and sought to improve its responsiveness to youth mental health issues.
You were named the first Mental Health In-Chief at Children’s Hospital Colorado. What does that job entail and how did it come about?
Over the last decade plus, the prevalence, complexity, and acuity of youth mental health challenges and conditions has been rising at a fever pitch. What’s interesting, though, is that there was a lag in responding to it. All of us in the mental health field felt this, as did parents and educators. You’d hear, “Hey, something’s different in my classroom. Something’s different for me as a parent. Something’s different in society,” but the healthcare field was slow to respond.
When I started as the Mental Health In-Chief in Colorado, more than 50% of the kids in our trauma Level One emergency department from this region were coming in after suicide attempts, significant trauma exposure, exacerbations of mental health conditions, and substance abuse. But the reaction to these numbers by hospitals was a bit slow because there’s a lack of integration of mental health with traditional physical health. Many hospitals are focused on being the best in specialty medicine — think cancer care or orthopedics — but the kids who show up in these hospitals are there because of mental health challenges.
In May 2021 I was working as a child psychiatrist in New York City, seeing kids in the ER at Bellevue Hospital and NYU Langone when Children’s Hospital Colorado declared a state of emergency for pediatric mental health. They reached out to me about applying for a job and I worked alongside Jenna Hausmann, CEO of the hospital, and department chair Dr. Neill Epperson to craft this role of Mental Health In-Chief. We wanted to elevate mental health and make sure there would be clinical expertise and experience at every table where we’d be making hard mental health-related decisions whether at the hospital, the academic health sciences or campus, or in the community. We’re cognizant that we’re sitting close to where the Aurora movie theater shooting and Columbine happened, and there’s the palpable impact, footprint, and legacy of trauma and gun violence and unmet mental health needs.
I’m specifically called the Mental Health In-Chief because there are many different parts of the mental health workforce I oversee — including psychiatrists, psychologists, Master’s clinicians from schools of social work, counseling, and marriage and family work, and nursing staff that are behavioral health focused. We also have a new fellowship program for nurse practitioners and physician assistants and just hired 6 family peer support specialists who we’ll be training in addition to training young people who have lived experience navigating mental health challenges to also do peer work.
Mental Health In-Chief is probably the best role I’ve ever had. It’s focusing on strategic visioning and planning and thinking about the safety and quality of our services. It’s about patient- and family- centeredness and including that voice within our official workforce. And it’s about identifying how to close the care gaps with the help of community, state, and national partners.
What do you see as the role of our society, whether it’s families, communities, schools, or other institutions in supporting youth mental health?
The further I am into my career it gets clearer to me just how much of a full societal effort it is to support youth mental health and well-being. Historically, we focused on the more acute part of the mental healthcare system and, as a result, some children’s hospitals built hundreds of inpatient and residential beds. We do need some of those longer-term solutions, but those alone are not the answer. And so many kids and families are turning to emergency rooms, crisis hotlines, and inpatient psychiatric units that are not necessarily the best fit to get these kids the support they need.
So, you start going upstream a little bit more and think, “Well, then maybe it’s outpatient care,” and how we need to ensure that every child has a primary medical home or a pediatrician or a health center where they can go. Maybe it’s making sure every child has access to a mental health home or counselor when they need someone to talk to, or if they need more complex assessment or diagnostics about why they’re struggling, whether it’s related to their emotions, behavior, or relationships.
Then you take this idea to the next level: “What if every child in America had access to a mental health home that was high quality, was close to home, and was part of their insurance coverage plan so that payment didn’t have to be out of pocket?” In Colorado, 80% of our mental health workforce is in private practice and is only self-pay. With the other 20%, the community mental health centers are overwhelmed with wait lists, as are hospital-based centers. It used to be that 1 in 5 kids was struggling with a mental health challenge. Now, in certain parts of our state, I can say it’s probably 8 out of 10 kids.
We all talk about some of the underlying societal issues — like isolation and loneliness and what’s happened to the fabric of our societies, our neighborhoods, and our families. We’re all aware of the influence of technology — how it’s shaping the young brain and the impact it’s having on developing relationships and potentially exposing kids to things that could be harmful.
One necessary shift in thinking is understanding that so much of what it takes to support youth and families doesn’t occur within the hospital walls. Mental health support and preventative interventions have to become better integrated in primary care, in schools, in early childhood and learning environments, in workplaces, and in communities. But because we have an atrocious mental health workforce supply and demand gap, we’re never going to meet the needs of the approximately 8 in 10 kids in rural communities who are facing mental health challenges and have no access to broadband for telehealth, let alone primary care or specialty mental healthcare.
How do you right size that sort of demand and the supply? Colorado is one of a couple of states that is developing AmeriCorps for youth mental health workers. They’re providing folks who are mostly college graduates with training and loan forgiveness. They’ll be deployed to middle schools and high schools across Colorado in typically underserved areas for healthcare and mental healthcare. We’re working on a lot of different strategies and a roadmap here in Colorado and have been connecting with folks across different states, thinking about ways to solve this crisis.
We’ll get to some of those strategies shortly, but first you referred to children boarding in hospitals when there are other options that would serve them better. How prevalent is that?
We’re talking about 2 populations of kids. There are kids who are boarding in emergency rooms across the country who have come in because they attempted suicide or written a suicide note, or are underweight from eating disorders, or can’t go to school because they’re so anxious, or can’t even get out of bed.
Whatever the crisis is, they’re coming for help. Their schools or primary care providers have sent them, but there’s no right support or right service or right level of care. They may be on an inpatient psychiatric unit because they’re just not safe at home, but it may not be the right bed for them, or it may not be in a place that’s close to home, or their insurance may not authorize it.
Then there are kids who just need to have a good therapist in the community or a psychiatry evaluation to determine if medications would help, but the wait times are months to years, depending on the specialty area. Or maybe this care isn’t covered by their insurance and the family is going to spend its rent paying for therapy appointments.
In our boarding crisis in Colorado, we talk about kids who are waiting more than 12 hours after their evaluation for that next level of care. It’s heartbreaking as a provider because in the past we would hand them a list and say, “Here are some people who are in network who you can reach out to,” but now there aren’t appointments for days or weeks. We’ve had to redesign all our crisis services so we’re now bridging kids who show up in the emergency departments and yet we still end up with this huge backlog. Sadly, every emergency department, every children’s hospital, and every general hospital is seeing this level of acuity.
What are some models you’ve encountered across the country that are working to support youth mental health?
I’d love to shine a light back on you in New Jersey. In many states, families have sued either state departments of Medicaid, or state departments of mental health, or — in New Jersey’s case — the Department of Children and Families, for failing to provide adequate care. But what New Jersey did was then invest [its settlement from the lawsuit] in what was needed to build a children’s system of care that not only focused on crisis and downstream effects of mental health conditions and challenges, but also in upstream prevention. Often, we call on New Jersey’s Department of Children and Families and Commissioner [Christine Norbut] Beyer to guide us in how best to build a system of care that is successful for all kids.
Ohio Rise is another interesting model where wraparound services are provided for the most vulnerable, complex kids and families who are struggling with social determinants of health and health-related social needs. Certain hospitals in Ohio have a goal of building healthy, safe surrounding neighborhoods and do so by ensuring their supply chains are fed by local, underprivileged communities, as well as building affordable housing locally, and focusing on employment needs of nearby residents.
The Texas Consortium is also worth mentioning. Taking tragic events like the school shootings in Santa Fe and Uvalde into account, they’re making massive investments — with funds from the state legislature and public dollars — into the child mental health workforce, into primary care integration, and into school telehealth consultations, along with the data analytics to track outcomes across the entire state.
There are many amazing projects and investments, but they’re occurring in silos. There’s no national youth mental health plan. There’s no universal access to a host of services that all children and families can easily access and deserve.
Have you come across any impressive models for addressing mental health in schools, specifically?
New York City has a very robust mental health system within its public schools. When I lived there, I had the privilege of working in school-based health centers. They’re unique in what they can provide. It’s a one-stop shop for preventive care, well-child visits, sick visits, immunizations, and mental healthcare. All kids can access these services if their parents sign a consent. For example, a student could go to see the nurse practitioner or mental health counselor during lunch period. These school-based clinics are federally funded and have matching dollars from the state.
Another good example is here in Colorado, in the Cherry Creek School District. Dozens of kids were leaving the school district to go to residential care or treatment programs out of state who were not returning to Cherry Creek. They also had a series of suicides in the district that rose almost to a contagion level of suicide risk. Based on these factors, they realized they had to do things differently.
With a bond fund that raised with the help of community members and a congressional-directed investment secured by their Representative they built the Traverse Academy, a public school that serves 4th-12th graders with mental health needs. The University of Colorado School of Medicine’s mental health team serves as the mental health team for Traverse Academy. There are classrooms that serve students with mild to more moderate acuity and those with more severe acuity, as well as a program to help kids transition back to their home school after a 2 or 3-month period. These students never have to leave their school district. They’re bussed in from all over the district and the school accepts all insurance. For students who can’t pay, there’s a fund that covers the costs.
We also have an incredible school partnership model in Durango, Colorado, a rural area in the southwestern part of our state. Our mental health team here at the University of Colorado and Children’s Hospital Colorado provide comprehensive evaluations, treatment recommendations, and supports for students referred to a mental health hub in Durango, launched by local pediatricians and school district champions. As part of this effort, our child psychiatry and psychology faculty also train students and fellows to enhance our rural mental health workforce. The trainees go to Durango several times a year to get to know the school and the community, and many of them end up working in rural settings after that because they’ve had this rich learning experience.
Thinking about families, what advice do you have for parents or caregivers seeing emerging mental health issues in their kids? Are there any resources you can suggest?
To start, it’s useful to identify ways to catch things early. You want to pay attention to your kid and get to know their unique strengths, their personalities, how they communicate, how they handle big emotions, stress, and change. Then it’s easier to recognize when something shifts or when something seems unusual for your child or when they seem to be struggling in some way.
Being able to pay attention and notice is a huge thing, because it’s stressful being a parent, between trying to work and getting your kids to where they need to be and making sure they’re safe. But you also want to have those spaces in your life that are more relaxed and open –maybe it’s the family dinner or other routines with your child — different ways and times in which you can check in with each other.
And if you notice that something’s not right or you’re worried about something, you want to check in and have a conversation with your child. As parents we often overthink it: “I should bring this up in this particular way. I don’t want to shut them down. I don’t want to come in too hard with all of my solutions.” Don’t be afraid to just ask and to open a conversation and listen, listen, listen and validate, validate, validate before you jump to problem-solving mode. You can say, “This must be hard. Tell me more. How can I help?”
As parents, we don’t get a playbook. No one gives you a handout and says, “Here you go. This is what you do in these situations.” So you need to go to the places you trust and seek help. Often, I’ll recommend going to your primary care provider or pediatrician if you’re worried about something or going to your school counselor or to people in the neighborhood or community that you trust. Sometimes your workplace can offer support. We always say in medicine, ”don’t worry alone.” Chances are whatever you’re dealing with, many other parents have dealt with it as well. So speak to other parents, as there’s some solace in that.
One silver lining of COVID was that people started talking a lot more about mental health. Our younger generations — Gen Zs and Alpha — they’re so much more willing to talk about things and are more upfront about their own challenges, and their friends’ challenges. There is so much more available online whether it’s the CDC website or the American Academy of Child and Adolescent Psychiatry, or the American Academy of Pediatrics. These sites have fact sheets for families about pretty much any topic you might be asking about.
I always like to remind people that our kids are watching us. Whether you avoid dealing with something, how you manage your own mental health issues when they come up, whether you talk openly about things, whether you yell — they see all of it. And it’s sometimes less about what we say, but how we act. We should remember that we can be and are important role models in for our kids.