Jessica L. Borelli Ph.D.


When Nobody's Checking

What happens to our kids’ mental health when we’re not looking?

Posted Jan 05, 2019

During a recent pediatric appointment for my children, I stopped and collected all of the informational pamphlets available in the office for parents regarding children’s health. These pamphlets were lengthy and written in language accessible to parents, the result of commendable effort on the part of the medical organization. After scouring through all of them, one thing was strikingly clear—these pamphlets all but ignore anything related to your child’s mental health. Those focusing on the first three years of life included a few bullet points about behaviors related to autism spectrum disorder, a developmental disorder with onset in early childhood, but there was not a single mention of any behaviors related to depression, anxiety, social difficulties, emotion awareness/expression, impulsivity, attention, repetitive or compulsive acts or habits, or self-harm. And it got me thinking about what amounts to complete neglect of mental health within the primary care sphere. Think about it: When was the last time you heard your child’s pediatrician ask if your child feels sad a lot, if your child experiences joy, and whether your child is able to express her feelings to adults in her life? Chances are you can’t because it’s never happened.

Our children get “checked” for all sorts of things at various different stages in their development. They get routine vision and hearing checks in school, dental cleanings and check-ups every six months are the standard, and pediatricians track their growth in height and weight fastidiously over time. But who’s checking on their mental health? Who stops to ask them how they are feeling about themselves, whether they feel safe in their communities, their homes, and their bodies?

Maybe nobody.

It’s not the pediatrician’s fault. Medicine at large—including pediatrics—has been slow to recognize that mental health is an important part of physical well-being. Yet there are numerous reasons why this can, and should, change, and why the physicians who monitor children’s health should consider their mental well-being to be an integral part of this picture.

iStock photo, used with permission
Why is mental health left out of well-checks and physicals?
Source: iStock photo, used with permission

Study after study has documented that psychological health is at least as strongly related to physical health outcomes as the villainous health behaviors we love to hate (e.g., smoking) or the positive ones we applaud en masse (e.g., regular exercise), making it completely clear that medicine needs to start paying attention to psychological health—and that insurance companies need to increase their coverage of routine and preventive mental health care services. True parity when it comes to mental health coverage entails covering preventive services and routine check-ups on mental health. Psychological health is likewise measurable, although future efforts could, and should, bolster our abilities in this arena. We can reliably measure indicators of both poor mental health (e.g., exceeding well-established thresholds for depression), and good mental health (e.g., attachment security)—longitudinal researchers assess these factors regularly, and with high levels of precision, with tools that are quickly scored and compared against normative benchmarks.

In our practice, we are incredibly aware that there are numerous factors (e.g., stigma, the bias of the medical field toward physical health) that prevent people from viewing mental health in the same way they view physical health—as something that should be routinely checked and monitored (rather than paying attention only when a problem emerges)—and so we’ve put time and resources into developing what we are calling “mental health well-checks,” which we offer on a yearly basis, much as physicians offer physicals. We aim to provide the service of characterizing a child’s overall mental health profile, in terms of their symptoms of psychopathology, but also their social and emotional functioning strengths and weaknesses. (What are his peer relationships like? Does she have someone she can confide in when she’s worried about something? What does he do when he’s angry?) To the greatest extent possible, children’s functioning is compared against developmental norms as well as against their own personal baselines. The goal of these mental health well-checks is to provide families with a means of assessing and tracking their children’s psychological health, to identify areas of growth for the child and family, and to provide the family with an opportunity to talk with a professional about the child’s emotional and psychological well-being. Much as physicals function to identify problems before they become critical, these mental health well-checks pay homage to decades of research literature suggesting that early intervention is, by and large, a crucial investment in prevention of more difficult issues down the line.

Although we are excited to be able to offer mental health well-checks in our practice, we recognize this is a drop in the bucket, certainly not a part of routine pediatrics, and that insurance companies will not cover the costs. At this point, the painful reality is that these services will be accessible only to the families who can afford them and choose to prioritize their children’s psychological health, meaning that the kids who may need these well-checks the most simply won’t get them. The cycle will, unfortunately, continue on.

We know from our daily lives as clinicians, parents, teachers, and family members that when nobody’s checking, things can go wrong without anybody knowing, but we also know what we need to do about this: advocate for psychological health to become the purview of pediatrics and family medicine. Well-checks and physicals should come to encompass both physical and mental health. We need to make sure that somebody is checking. Somebody who knows something about children’s development and mental health. Because somebody needs to know.